Did the injury involve:
Fatality
Hospitalization
Amputation
Fracture
Severe Cut
Severe Burn
Severe Shock
Complete Loss of Consciousness
Date of incident
Month Day Year
This is a report of a:
Lost Time
Dr. Visit Only
First Aid Only
Near Miss
This report is made by:
Supervisor
Team
What personal protective equipment was being used (if any)?
Describe step-by-step the events leading up to the incident (who, what, when, where, why) include names of any machines,
parts, objects, tools, materials, or other important details.
Name
First Name Last Name
Gender:
Male
Female
Department
Job title at time of
incident
Part(s) of body injured:
Nature of injury
Abrasion, scrapes
Amputation
Broken bone
Bruise
Burn (heat)
Burn (chemical)
Concussion (to the head)
Crushing Injury
Cut, laceration, puncture
Hernia
Illness
Sprain, strain
Damage to a body system
This employee works:
Regular full time
Regular part time
Seasonal
Temporary
Months with this
employer
Months doing this job
Exact location of incident
Exact time of incident
Hour Minute
s
What part of employee's
workday?
Entering or leaving work
Doing normal work activities
During meal period
During break
Working overtime
Name of witnesses
Describe the root cause
by using the Five Whys:
Was the incident caused by an unsafe work condition? (i.e. faulty equipment, unsafe ventilation, insufficient training)
Yes
No
Was the incident caused by an unsafe act? (i.e. improper lifting, failure to wear appropriate PPE, failure to follow identified
safety protocols, etc.)
Yes
No
What changes do you suggest to prevent this incident/near-miss from happening again?
Stop this activity
Guard the hazard
Train the employee(s)
Train the supervisor(s)
Redesign the task steps
Redesign work station
Write a new policy/rule
Enforce existing policy
What should be (or has been) done to carry out the suggestion(s) checked above?
Supervisor Name
First Name Last Name
E-mail
Title
Department
Date
Month Day Year
Names of investigation
team members:
Signature
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