REQUIRED-may be sent in separately from page 1
H. SUPERVISOR’S INVESTIGATION OF INCIDENT
WHAT HAPPENED? (Be specific; include heights, weight, repetitions, dimensions, lighting etc.)
I. WHY DID IT HAPPEN?
J. WHAT CORRECTIVE ACTION IS BEING TAKEN TO ELIMINATE POTENTIAL FOR FURTHER INJURY OR ILLNESS?
What specifically is being done? How are we addressing root causes, behavior, hazards, training?
K. DISCIPLINARY ACTION TAKEN: YES NO
L. FALL FROM DIFFERENT LEVEL INFORMATION:
Was a ladder involved? Describe:
M. CAUSE OF INCIDENT – UNSAFE ACT: BY INJURED PERSON -or- BY OTHER PERSON (NAME):
Failure to warn or signal
Working/reaching moving equipment
Overloading equipment or containers
Making safety devise inoperative
Failure to shut off or lockout
Wearing unsafe attire, jewelry etc.
Not observing where walking or driving
Operating at unsafe speed
Operating without safety device
Operating without authority
Using unsafe tools or equipment
N. CAUSE OF INCIDENT – UNSAFE CONDITION
Wet/slippery/icy floor or ground
Faulty machine or equipment
O. CAUSE INFORMATION
Was employee doing his/her regularly assigned job? Explain a “no” answer below.
Did you (supervisor) provide proper instruction on how to do the job safely? Explain a “no” answer below.
Was employee doing this job as you had instructed? Explain a “no” answer below.
Was proper equipment provided? Explain a “no” answer below.
Was the employee using the equipment? Using it properly? Explain a “no” answer below.
Have you had similar incidents with this or other equipment in you area? Explain a “yes” answer below.
Additional comments from above:
P. SAFETY INVESTIGATION AND FOLLOW-UP
Was the investigation thorough?
Was corrective action taken?
Did the supervisor make every attempt to help eliminate the unsafe act or hazard?
Did the employee make every attempt to help eliminate the unsafe act of hazard?
Explanation and recommendations:
Q. INVESTIGATION COMPLETED BY: