Fillable RKERS COMPENSATION INCIDENT INVESTIGATION REPORT WO (Rogers State University)

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RKERS COMPENSATION INCIDENT INVESTIGATION REPORT WO (Rogers State University)

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1
State of Oklahoma
WO
RKERS’ COMPENSATION INCIDENT INVESTIGATION REPORT
Check Box: INJURY ILLNESS NEAR MISS
Email completed form to: WorkComp@omes.ok.gov or fax to: 405-522-4442
A. EMPLOYEE INFORMATION: ALL FIELDS REQUIRED
EMPLOYEE’S NAME
M/F
DOB
COMPLETE SSN
JOB TITLE/CLASSIFICATION
EMPLOYEE ID NUMBER
FT
Temp
Seasonal
DATE OF HIRE
TIME WORK DAY BEGINS
TIME OF INCIDENT
(AM / PM)
AGENCY #
DEPT
OVERTIME?
Y N
SHIFT
1 2 3
LOST TIME FROM WORK?
Yes No
EMPLOYEE RETURNED TO WORK?
Yes No If yes, what date?
AVERAGE WEEKLY WAGE
AT THE TIME OF THE INCIDENT THE EMPLOYEE WAS: on break on lunch arriving/leaving work for the day
performing the following task or tasks:
EMPLOYEE’S HOME ADDRESS
EMPLOYEE’S PHONE # Home & Cell & EMAIL
SUPERVISOR’S NAME, PHONE # & EMAIL
B. INCIDENT DETAILS: Is there any reason to question how this incident occurred? Yes No Explain:
LOCATION/ADDRESS (where injury occurred):
DESCRIBE WHAT HAPPENED:
C. WAS MEDICAL TREATMENT REQUIRED? Yes No
1. If yes, what type of treatment and where was it received?
2. Is there a follow up appointment and if so, when is it?
3. Was employee put on restricted duty?
4. Can restricted duty be accomodated?
D. PART OF BODY INVOLVED (be specific: left, right, upper, lower, etc.)
E. TYPE OF INCIDENT
Caught on or in
Ingestion
Inhalation
Fall-same level
Bitten
Overexertion
Electrical
Chemical – skin
Fall-different level
Lifting
Struck by/against
Slip or Trip
Explosion
Heat/Cold exposure
Cut
Auto accident
Cumulative injury
Puncture
Other __________
F. WITNESS TO INJURY (attach witness statement to investigation page 2)
NAME #1:
PHONE #
NAME #2:
PHONE #
G. FORM COMPLETED BY:
Print Name & Title
Phone # & Email Address
Date & Time Injury Reported to Agency
2
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?
ROOT CAUSE #1:
ROOT CAUSE #2:
ROOT CAUSE #3:
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
Describe:
L. FALL FROM DIFFERENT LEVEL INFORMATION:
Height:
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
Moving objects too heavy
Disregard instructions
Operating at unsafe speed
Not wearing PPE
Horseplay
Operating without safety device
Operating without authority
Lack of training
Taking unsafe position
Using unsafe tools or equipment
No unsafe act
Negligence
Employee misconduct
Other_________________________
N. CAUSE OF INCIDENT – UNSAFE CONDITION
Hazardous arrangement
Poor Housekeeping
Wet/slippery/icy floor or ground
Insufficient lighting
Unsafe design
Other __________________________
Insufficient guarding
Ergonomic deficiency
Other __________________________
Faulty machine or equipment
Hazardous work method
Other __________________________
Insufficient ventilation
Poor air quality
Other __________________________
O. CAUSE INFORMATION
YES
NO
1.
Was employee doing his/her regularly assigned job? Explain a “no” answer below.
2.
Did you (supervisor) provide proper instruction on how to do the job safely? Explain a “no” answer below.
3.
Was employee doing this job as you had instructed? Explain a “no” answer below.
4.
Was proper equipment provided? Explain a “no” answer below.
5.
Was the employee using the equipment? Using it properly? Explain a “no” answer below.
6.
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
YES
NO
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:
Print Name & Title
Phone # & Email Address
Date Completed
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RKERS COMPENSATION INCIDENT INVESTIGATION REPORT WO (Rogers State University)

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Completed 9 February 2021

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