3.930 RCUH Safety & Accident Prevention Program
RCUH Form B-3
Created 7/2002, Revised 02/2004, 05/2004, 3/2005, 09/2009, 10/2009, 04/2010, 10/2013)
Page 3 of 3
PART B: ACCIDENT INVESTIGATION:
1. What type of safety equipment and/or procedure was involved in this work process? Did the employee use the
equipment or follow the procedure?
2. What kind of actions do you plan to implement to prevent this type of accident from recurring?
3. Have you instructed the employee on how to avoid the recurrence? How?
4. Was a Safety Rule violated? If so, has the employee been disciplined for violating the safety rule?
5. Please include photographs of the accident site to help better describe the location, environment, or other factors
that caused/contributed to the accident. Number each photo and provide an explanation of what each photo
represents. DO NOT include photos of the injury or injured employee.
Additional comments relating to Accident Prevention and/or investigation:
STATEMENT OF CERTIFICATIONS (Any falsification of this report may result in disciplinary action)
__________________________________________ _________________________________________________________________ ___________________
Employee Name Employee Signature Date
_________________________ ______________________ ______________________________________________
Work Phone Number Home Phone Number E-mail Address
__________________________________________ _________________________________________________________________ ___________________
Supervisor Name Supervisor Signature Date
_________________________ ______________________ ______________________________________________
Phone Number Fax Number E-mail Address
__________________________________________ _________________________________________________________________ ___________________
Project Safety Coordinator Name Project Safety Coordinator Signature Date
_________________________ ______________________ ______________________________________________
Phone Number Fax Number E-mail Address
REVIEWED BY PRINCIPAL INVESTIGATOR:
__________________________________________ _________________________________________________________________ ___________________
Principal Investigator Name Principal Investigator Signature Date
_________________________ ______________________ ______________________________________________
Phone Number Fax Number E-mail Address
REMINDERS:
1. If this is more than a “first aid” type injury or if the employee will lose time from work, the Employee must be seen by a Physician.
2. Complete and Attach EMPLOYEE/CLAIMANT CONSENT FORM (B-4) to this report and send both in to the RCUH Director of Human Resources immediately. Fax to 808/956-9423 AND mail original forms
to John A Burns Hall 4
th
Floor Makai Wing, 1601 East West Road, Honolulu, HI 96822.
3. Scan and email photo(s) of the injury(ies), location/work environment, object that may have caused the injury, etc. to rcuhhr@rcuh.com.
4. Refer to RCUH 3.580 Workers’ Compensation and 3.930 Safety and Accident Prevention Program policies for more information.
5. Provide the Employee with the “Guidelines to Employee Memo” located on the WC policy.
