CCFR 20.8
Charlton County Fire & Rescue
The Desire to
The Courage to
The Ability to
Personal Injury/Illness Investigation Report
Station Date
Name of Injured Date of Birth
Address of Injured
Phone Age Sex Height Weight
Occupation Job Title Department ID
Years with Dept. Date of Injury Time of Injury Date Reported Time Reported
Accident Reported To
Nature of Injury
Fractures Multiple Injury Heat Exhaustion, Fatigue
Inflammation Recurrence Abrasions, Contusions, Bruises
Infectious Disease Strain, Sprain, Torn Ligament Heart Malfunction
Frostbite, Cold Exposure Cuts, Lacerations, Punctures Eye Injury
Pinched Nerve, Ruptured Disk Inhalation, Fumes Burns
Electric Shock Inhalation, Smoke Other
Chemical Injury
Parts of Body Affected
Multiple Parts Abdomen Knee(s)
Head Back Ankle(s)
Eye(s) Heart Foot/Feet
Ear(s) Groin Ribs
Neck Arm Hip
Shoulder Hand Other
Chest Finger
Lung Leg(s)
Where Injury Occurred
Station Maintenance Fundraising Standing By Station for Call
Apparatus Maintenance Convention Training
Emergency Scene Emergency Vehicle to Emergency Auxiliary Services
Private Auto to Emergency Emergency Vehicle Non-Emergency Responding/Returning to Emergency
Private Auto Non-Emergency Parades, Picnics, Contests (Non-Vehicle)
Cause of Injury
Fall Improper Lifting Inadequate Illumination
Weather Horseplay Inadequate Ventilation
Making Safety Devices Inoperative Structural Collapse Lack of Knowledge or Skill
Using Defective Equipment Inadequate Guards or Protection Irrational Civilian
Using Equipment Improperly Back Draft Communication
Failure to Use Personal Protection Equipment Improper Placement Abuse or Misuse
Struck By Object Civil Disturbance Other
Injury Occurred - Performing What Task?
Forcible Entry Overhauling Rescue Operation
Using Ladders Salvage Administering Medical Aid
Advancing/Directing Hose Line Servicing/Repairing Equipment Physical Fitness
Ventilating Extrication Other
Witness(es) to Injury:
Injured Person’s Signature Date
CCFR 20.8
Investigation Report
Thoroughly describe accident: (What, How, Where, Equipment, Activity, etc.)
Hospitalized or Treated, Where? (Include Address)
Name and Address of Physician: (Include Referral)
Did the injury require individual to perform limited duties, or to be assigned to other duties or positions? YES NO
If yes, what
duties or position?
And, what period of time?
Investigated by Title Date
Safety Officer’s Report
What Acts, Failures to Act and/or Conditions Contributed Most Directly to This Accident? (Immediate Cause)
What Are the Basic or Fundamental Reasons for the Existence of These Acts and/or Conditions? (Fundamental Cause)
What Action Has or Will Be Taken to Prevent Recurrence? Place “X” By Items Completed.
Reviewed by Safety Officer Title Date