To determine what went wrong in the workplace that resulted in an accident, or near miss, so that effective corrective action can be taken to prevent recurrence.
The supervisor of the department in which the incident, illness or near miss occurred shall assure a complete and thorough accident investigation is conducted. Copies of this report shall be sent to the city administrator for processing and follow-up.
The city administrator needs to review the report to assure completeness and accuracy and maintain a copy in a central accident file.
City management should maintain a copy of any accident report in the employee’s personnel file.
The city administrator can assist the supervisor in incident investigation as required.
Employees must immediately report all occupational incidents, illness and near misses to their immediate supervisor WITHIN 24 HOURS.
The city administrator needs to assure the proper notification of authorities per Federal, State, and Local regulations.
The supervisor shall report to the designated employee safety committee investigative team who will then investigate and report back to the committee.
Contact emergency first aid services
Render first aid
Activate investigative unit
The accident investigation forms shall be completed as part of the investigation.
Panel interview with supervisor & employee - employee safety committee may make recommendations. Disciplinary action will be at the city administrator’s discretion.
Supervisor’s Accident
Investigation
(To be completed by
the employee’s supervisor or other responsible administrative official)
Location where
accident occurred Employer’s
Premises: O Yes O No
Date of accident or illness
Job site: O Yes O No ________________________
Who was injured? O Employee Time
of accident O a.m.
O Non-Employee O p.m.
Length of time with
firm Job title or occupation Name of
dept. normally assigned to
How long has employee
worked at job where injury or illness occurred? ___________________
What property was
damaged? Property
owned by
What was employee
doing when injury/illness occurred? What machine or tool? What operation?
____________________________________________________________________________________________
____________________________________________________________________________________________
How did
injury/illness occur? List all objects and substances involved.
___________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Part of body affected Any prior physical defects?
Is so, what?
O Yes O No __
Nature and extent of injury/illness and property
damaged (be specific) ___________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
PLEASE INDICATE
ALL OF THE FOLLOWING WHICH CONTRIBUTED TO THE INJURY OR ILLNESS
____Improper
instructions ____Failure
to lockout ____Unsafe arrangement or
process
____Lack of training or skill ____Unsafe position ____Poor
ventilation
____Operating without authority ____Improper dress ____Improper guarding
____Horseplay ____Improper
protective equipment ____Improper
maintenance
____Physical or mental impairment ____Unsafe equipment ____Inoperative
safety device
____Failure to secure ____Poor
housekeeping ____Other
_______________
Was PPE/Safety Equipment used? ________________
Was there property damage? _______________
Was medical treatment sought? ______________ If so, where?
___________________________________
Supervisor’s corrective action to insure this type of
accident does not reoccur: _____________________________
____________________________________________________________________________________________
Was employee trained in the appropriate use of
Personal Protective Equipment/proper safety procedures? _______
Was employee cautioned for failure to use Personal
Protective Equipment/proper safety procedures? ___________
__________________________________ _________________________________ _________________
Supervisor’s name Supervisor’s
signature Date
Employee’s Report of
Injury
(To be completed by
the employee)
Employee’s Name:
________________________________________ Male
_______ Female _______
Date of birth:
_____/_____/_____ Home Telephone #
(_____) _______________
Home Address:
_______________________________________________________________________________
City: ___________________________________ State: ____________ Zip Code: ____________
Present
classification: _____________________________ How
long employed here: _________________
Location of accident:
__________________________________________________________________________
Date of accident:
_______________________ Time
of accident: _________________________
Describe fully how
accident occurred:
_____________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
PLEASE INDICATE
ALL OF THE FOLLOWING WHICH CONTRIBUTED TO THE INJURY OR ILLNESS
____Improper
instructions ____Failure
to lockout ____Unsafe
arrangement or
process
____Lack of training or skill ____Unsafe position ____Poor ventilation
____Operating without authority ____Improper dress ____Improper
guarding
____Horseplay ____Improper
protective equipment ____Improper
maintenance
____Physical or mental impairment ____Unsafe equipment ____Inoperative
safety device
____Failure to secure ____Poor
housekeeping ____Other
_______________
Describe bodily
injury sustained (be specific about body part(s) affected):
________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Recommendation on how
to prevent this accident from recurring:
_______________________________________
____________________________________________________________________________________________
Name of Supervisor:
__________________________________
Name(s) of Witness(es):
________________________________________________________________________
When did you report
the accident to your supervisor? ____________________________________________
Was medical treatment
sought? ____________________ If so, where?
___________________________________
Was there property
damage? ____________________________________________________________________
__________________________________________________ ______________________________
Employee Signature Date
Accident Witness
Statement
(To be completed by
accident witness)
Injured Employee’s
Name: ______________________________________________________________________
Name of Witness:
_____________________________________________________________________________
Home Address of
Witness: ______________________________________________________________________
City:
___________________________________ State:
____________ Zip Code:
____________
Location of accident:
__________________________________________________________________________
Date of accident:
_______________________ Time
of accident: _________________________
Describe fully how
accident occurred: ____________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Describe bodily
injury sustained (be specific about body part(s) affected):
________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
______________________________________________________ _______________________
Witness Signature Date