CCI First Report of Incident
|Incident Report | |
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|Project Name:________________________ | |
|Project Number:_______________________ | |
| First Report of Incident |Rev -10-2015 |
|Project |Date of Incident: |Time: AM or PM |Day of Week |
|Data | | | |
| |Date of Report: |Time of Report: AM or PM |
| |Project Manager/Resident Engineer: |
| |Superintendent /Supervisor: |
| |Drug Screen (s) Administered: Y or N |If Yes, List Employees: |
| |Are There Any Witnesses? Y or N |If Yes, List Employees: |See Page 5 for Witness |
| | | |Instructions |
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| Personal|Employee Name: |SS#: |Sex: M - F |
| | | | |
|Data | | | |
| |Employee Home | |Date of Birth: |
| |Address: | | |
| | | |Phone: |
| |Occupation/Title: |Years Experience: |Date of Hire: |Sub? Y or N |
| |
|Personal |Onsite First Aid Given: Y or N |If Yes, by Whom: |
|Injury –| | |
|WC ( | | |
|N/A | | |
| |Offsite Medical Treatment: Y or N |If Yes, Treating Facility: |
| |Date Treatment Given: |Treating Facility Phone: |
| |Has employee returned to work? Y or N |If Yes, When? If No, Probable length of disability? |
| |Shade the Specific Body Part (s) Injured: |Injury tracking (See Page 6 for Instructions) |
| |[pic] |Injury Type: |Part of Body Injured: |
| | |Nature of Injury: |Type of Treatment: |
| | |Description of Injury: |
| | |List any doctor restrictions: |# Days: |
| | |List PPE worn at the time of the incident: |
| | |Incident Designation: |
| | |First Aid Only |Restricted Work |
| | |Non Recordable – Medical Treatment|Recordable - Lost Time |
| | |Recordable – Medical Treatment |Claim Denied |
|Supplemental Injury Information (Enter Corresponding Letter(s) for Injury/Illness Incidents Only) |
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|If JTS employee injured |
|Employee Name: ____________________________ Employee Number: ___________________________ |
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|If non-JTS employee injured |
|Employee Name: ____________________________ Company: ____________________________________ |
|Contractor Contact: ________________________ Phone number: ________________________________ |
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|Injury Type: |
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|a. Allergic Reaction |
|m. Electric Shock |
|x. Multiple (Specify) |
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|b. Amputation |
|n. Foreign Body in eye |
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|c. Asphyxia |
|o. Fracture |
|y. Muscle Spasms |
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|d. Bruise/Contusion/Abrasion |
|p. Freezing/Frost Bite |
|z. Other (Specify) |
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|e. Burn (Chemical) |
|q. Headache |
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|f. Burn/Scald (Heat) |
|r. Hearing Loss |
|aa. Poisoning (Systemic) |
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|g. Cancer |
|s. Heat Exhaustion |
|bb. Puncture |
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|h. Carpal Tunnel |
|t. Hernia |
|cc. Radiation Effects |
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|i. Concussion |
|u. Infection |
|dd. Strain/Sprain |
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|j. Cut/Laceration |
|v. Irritation to eye |
|ee. Tendonitits |
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|k. Dermatitis |
|w. Ligament Damage |
|ff. Wrist Pain |
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|l. Dislocation |
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|Part of Body Injured: |
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|a. Abdomen |
|o. Hand(s) |
|aa. Neck |
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|b. Ankle(s) |
|p. Head |
|bb. Nervous System |
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|c. Arms (multiple) |
|q. Hip(s) |
|cc. Nose |
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|d. Back |
|r. Kidney |
|dd. Other (Specify) |
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|e. Blood |
|s. Knee(s) |
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|f. Body System |
|t. Leg(s) |
|ee. Reproductive System |
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|g. Buttocks |
|u. Liver |
|ff. Shoulder(s) |
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|h. Chest/Ribs |
|v. Lower (Arms) |
|gg. Throat |
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|i. Ear(s) |
|w. Lower (Legs) |
|hh. Toe(s) |
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|j. Elbow(s) |
|x. Lung |
|ii. Upper (Arms) |
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|k. Eye(s) |
|y. Mind |
|jj. Upper (Legs) |
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|l. Face |
|z. Multiple (Specify) |
|kk. Wrists |
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|m. Finger(s) |
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|n. Foot/Feet |
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|Nature of Injury: |
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|a. Absorption |
|h. Inhalation |
|n. Overexertion |
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|b. Bite/Sting/Scratch |
|i. Lifting |
|o. Repeated Motion/Pressure |
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|c. Cardiovascular/Respiratory System |
|j. Mental Stress |
|p. Rubbed/Abraded |
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|Failure |
|k. Motor Vehicle Accident |
|q. Shock |
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|d. Caught In or Between |
|l. Multiple (Specify) |
|r. Struck Against |
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|e. Fall (from Elevation) |
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|s. Struck By |
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|f. Fall (Same Level) |
|m. Other (Specify) |
|t. Workplace Violence |
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|g. Ingestion |
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|Type of Treatment: |
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|a. Admission to hospital/medical facility |
|i. Nonprescription medication |
|r. Soaking Therapy – one treatment |
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|b. Application of bandages |
|j. None |
|s. Stitches/sutures |
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|c. Cold/heat compression – multiple |
|k. Observation |
|t. Tetanus |
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|treatment |
|l. Other (Specify) |
|u. Treatment for Infection |
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|d. Cold/heat compression - one |
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|v. Treatment for 2nd/3rd degree burns |
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|treatment |
|m. Prescription – multiple dose |
|w. Use of antiseptics – mult. treatment |
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|e. First-degree burn treatment |
|n. Prescription – single dose |
|x. Use of antiseptics – one treatment |
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|f. Heat Therapy – multiple treatment |
|o. Removal of Foreign bodies |
|y. Whirlpool bath therapy - multiple |
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|g. Heat Therapy – one treatment |
|p. Skin Removal |
|z. Whirlpool therapy – one treatment |
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|h. Multiple (Specify) |
|q. Soaking Therapy – multiple |
|aa. X-rays negative |
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|treatment |
|bb. X-rays positive |
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|ACCIDENTS RESULTING IN PROPERTY DAMAGE, SPILL, EQUIPMENT DAMAGE OR OTHER |
|Property |Describe Property Damaged: |
|Damage ( N/A| |
| |Property Owner: |Phone #: |
| |Property Owner Address: | |
| | | |
| |Estimated Amount: $ |Other Pertinent Info: |
| |
|SPILL or |Substance (attach SDS): |Estimated Qty: |
|release ( | | |
|N/A | | |
| |Location: |Phone #: |
| |Spill Response: | |
| | | |
| |Did spill/release move off property where work was performed? Y or N |
| |Spill/Release From: |Spill/Release To: |
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|Environmental/|Describe The Release or Emission & Location: |
|Permit Issue | |
|( N/A | |
| | |
| | |
| | |
| |Substance & Estimated Quantity: |
| |Duration of Permit Exceedance: |Environmental Contacts Notified: Y or N |
| |
| Auto & |Unit Description: |Unit/Serial Number: |
|Equipment| | |
|DAMAGE | | |
|( N/A | | |
| |Rental: Y or N |If yes, Rental ID#: |
| |Rented From: | |Estimated |
| | | |Damage: |
| | | |(Attach any repair estimates) |
| |Rental Company Phone: | |
| |Did Operator/Driver obey all applicable safety rules or D.O.T. Motor Vehicle Laws? |
| |Y or N If NO, list exceptions: |
| |Did Authorities Respond (fire, police, ambulance, |Responding Authority: |
| |etc)? Y or N | |
| |Police Report #: | |
| | |Contact Person: |
| | |Phone: |
| |Was there Other Vehicle or Property Damage: Y or N |Owner’s Name & Phone #: |
| | |Driver’s Name (if different than above) & Phone #: |
| | |License NO. & State: |
| |For Auto Damage, Shade the Specific areas damaged: |
| |
|Descripti|To be completed for all incidents |
|on of | |
|Incident | |
| |Describe in detail the circumstances of the incident. Give a chronological sequence of events. If materials, equipment and/or vehicles were |
| |involved, start before they were brought to the incident scene and describe the who, what, where when, and how the incident happened in your words |
| |below (specifically detail who, what, where, when, how, and why you believe the incident happened): |
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|To be completed for all incidents |
|(Show position and any relative distances of employee(s), vehicle(s), equipment, pedestrians, property, etc., and indicate an arrow of direction for each if |
|travel or moving equipment was involved): |
|Diagram of Incident |
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|WITNESS STATEMENTS – FOR ALL INCIDNETS |
|Witness Statement: Attach Witness to applicable incidents |
|Witness Name: |Witness Name: |
|Witness Name: |Witness Name: |
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|Witness Name: |SS # - - |
|(Please Print) | |
|Witness Address: |Work Phone: |Home Phone: |
|Date and Time of incident: am/pm |List other Witnesses: |
|Supervisor Notified on Date and Time: am/pm | |
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|This is what happened (include who, what, where, when, how and why): |
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|Do you recall anything unusual or unexpected that happened? Yes or No If Yes Explain: |
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|Are there work conditions that contributed to this injury? Yes or No If Yes Explain: |
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|How would you prevent this incident from happening in the future? |
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|Please use and attach additional pages if necessary |Witness Signature: |Date: |
LESSONS LEARNED & CORRECTIVE ACTIONS TAKEN
FOR ALL INCIDENTS
|Lessons |Did the “Job Hazard Analysis” or “Task Hazard Analysis” discuss the potential for this incident, and the safe work procedures to be followed to |
|Learned |prevent it? YES or NO. Please attach a copy of applicable document(s) to support your findings. |
|To be | |
|completed | |
|for all | |
|incidents | |
| |What was the Root Cause(s) of the Incident? |
| |Contributing Factor(s) to the Incident: (weather, lighting, traffic control plan, communication of hazards, etc.) |
| |Corrective Action(s)That Were Taken to Prevent Reoccurrence: |
|Participants of in the Incident Analysis |Management Review |
|Name/Title or Trade |Date |Name |Date |
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|Employee | | | |
|Signature: | | | |
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|Employee | | | |
|Signature: | | | |
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-----------------------
Incident Number________
← Preliminary Report
← Final Report
................
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