UNSAFE ACTIONS that caused or contributed to the incident (check all that apply)
Unsafe body position or posture (improper lifting) Removing or modifying safety devices or guards
Lack of or improper personal protective equipment Operating at unsafe speeds
Failure to secure against unexpected movement Operating equipment without authority
Failure to warn or signal as required Service hazardous equipment or unauthorized
modifications
Horseplay, distracting, teasing, etc. Riding hazardous moving equipment
Improper tool inspection, maintenance or use Ignore safety rules, procedures, or policies
Using a defective tool or piece of equipment Other (explain):
PERSONAL or JOB FACTORS that caused or contributed to the incident (check all that apply)
Poor morale (short-cut, express hostility, attention, etc.) Lack of training or understanding (policies,
rules, procedures)
Physical/mental stress (fatigue, sub abuse, family issue, etc.) Lack of equipment, assistance or supervision
POLICY INFRACTION that caused or contributed to the incident (check all that apply)
Was there an infraction of a job rule, policy, practice, or procedure? Yes No
If yes, please describe the rule and infraction in detail:
If there was an infraction, were the proper policies/procedures reviewed with the worker? Yes No
Was the policy/procedure review documented (meeting notes, warning notice, etc.)? Yes No
Is there any reason to believe this is a non-work related injury/incident? Yes No
If yes, please explain:
I state the above is true and correct to the best of my knowledge.
Signature of Supervisor / Investigator Date
Recvd: ____________________
Training documentation Employment documentation Witness Statement(s)
Feb 2014 Page | 2
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