Written witness statements:
What personal protective equipment was being used (if any)?
Describe, step-by-step the events that led up to the injury. Include names of any machines, parts, objects, tools, materials
and other important details.
Description continued on attachedsheets:
Step 3: Why did the incident happen?
Unsafe workplace conditions: (Check all that apply)
Safety device is defective
Tool or equipment defective
Workstation layout is hazardous
__Lack of needed personal protective equipment
__Lack of appropriate equipment / tools Unsafe
__No training or insufficient training
Unsafe acts by people: (Check all that apply)
__Operating without permission
Operating at unsafe speed
__Servicing equipment that has power to it
Making a safety device inoperative
__Using defective equipment
__Using equipment in an unapproved way
__Taking an unsafe position or posture
Distraction, teasing, horseplay
__Failure to wear personal protective equipment
__Failure to use the available equipment / tools
Why did the unsafe conditions exist?
Why did the unsafe acts occur?
Is there a reward (such as “the job can be done more q
uickly”, or “the product is less likely to be damaged”) that may
have encouraged the unsafe conditions or acts? Yes No
If yes, describe:
Were the unsafe acts or conditions reported prior to the incident?
Have there been similar incidents or near misses prior to this one?