Appendix E · Municipal Policies

29. Accident Investigation

3 sections

OBJECTIVE

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.

RESPONSIBILITIES

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.

PROCEDURES

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

OBJECTIVE​

RESPONSIBILITIES​

PROCEDURES​

OBJECTIVE

RESPONSIBILITIES

PROCEDURES