HR200 Accident Investigation Report

Imp. 08/15/2014

INCIDENT INVESTIGATION REPORT The Branch Manager or branch representative must consider accident investigation an immediate priority. Valuable

information can be lost if you do not act quickly to secure the facts surrounding an accident. Please print clearly, use full names

and be specific as possible. This form is to be completed for all incidents that result in a personal injury.

1. Reporting Branch Information:

Branch: Completed By:

Date of Incident: Date Notified of Incident:

2. Employee Information:

Employee Name: Employee ID:

Job Title / Job Duty: (Be Specific)

Job Description: (The specific activity the employee was performing)

How long has the employee worked on this assignment?

Start Time of Work Day : What was the scheduled quit time?

Has the employees current address been verified in HqWebConnect and updated if necessary

3. Incident Location:

Customer ID: Customer Name:

Jobsite ID:

Jobsite Address

(city & state):

Jobsite Zip

Supervisors Name (first & last) Telephone #

Exact location of

the Incident:

Exact Time of Incident

4. Incident Description:

What Specific activity was the employee doing at the time of the incident:

Were there any witnesses to the incident? (If yes get their name, phone number and a statement)

Name Phone Number

1.

2.

3.

4.

HR200 Accident Investigation Report

Imp. 08/15/2014

Personal Protective Equipment used

� Foot Protection � Head Protection � Hand Protection

� Face/Eye Protection � Apron/Chaps � Back Belt

� Fall Protection � Lifting Assistance Device � Respiratory Protection

� NO PPE USED � Other__________________

Describe, step-by-step the events that led up to the injury. Include the names if any machines, parts, objects,

tool, materials and other important details.

Description continued on attached sheets

Are there any photos of the incident location? (If yes attach to report)

Was a safety inspection done after the incident? (If yes attach a copy to report)

Why did the Incident happen? Direct Causes

� Struck by Flying/ Falling Object � Struck by an Swinging/Rolling Object � Hazardous Material Exposure � Assault / Fight (explain why below)

� Caught in/Under/Between Objects � Blood/Body Fluid Exposure � Vehicle / Equipment Accident � Repetitive Motion

� Electrocution � Rubbed or Abraded by Object � Noise Hazard Exposure � Slip / Trip

� Fall � Heat exposure � Fire Hazard Exposure � Other ____________________

Indirect causes

Unsafe workplace conditions: (Check all that apply)

� Inadequate guard / Barrier � Unguarded hazard � Safety device is defective � Tool or equipment defective � Workstation layout is hazardous � Unsafe lighting � Unsafe ventilation � Lack of needed personal protective equipment � Lack of appropriate equipment / tools � Unsafe clothing � No training or insufficient training � Wet / Slippery Surface � Equipment Malfunction � Foreign Matter on Floor � Other: _________________________________________

Unsafe acts by people: (Check all that apply)

� Operating without permission � Operating at unsafe speed � Servicing equipment that has power to it � Removing safety guards or devices � Using defective equipment � Using equipment in an unapproved way � Unsafe lifting � Taking an unsafe position or posture � Distraction, teasing, horseplay � Failure to wear personal protective equipment � Failure to use the available equipment / tools � Failure to comply with Policies / Procedures � Failure to Follow Instructions � Under the Influence of Drugs or Alcohol (Get Statements) � Other: __________________________________

Why did the unsafe condition exist?

Why did the unsafe act occur?

Was the employee drug / alcohol tested after the Incident? Test Date:

HR200 Accident Investigation Report

Imp. 08/15/2014

5. Injury Description:

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 � Dehydration � Heat Exhaustion / Heat Stroke � Other _______________

Part of the body affected (shade all that apply)

Location of Injury

� Head � Hand (s) R / L / Both � Neck � Eye (s) R / L / Both � Chest � Shoulder (s) R / L / Both � Back � Arm (s) R / L / Both � Trunk � Wrist (s) R / L / Both � Abdomen � Finger (s) Th / I / M / R / P � Groin � Hip (s) R / L / Both � Skin � Ankle (s) R / L / Both � Digestive � Foot (s) R / L / Both � Respiratory � Toe (s) R / L / Both � Circulatory � Other __________________

Initial Treatment � First Aid by Employee � First Aid by EMT / Paramedics � First Aid by Clinic/Hospital/ Physician � Medical treatment by Clinic/Hospital/ Physician

� Hospitalized � Fatality � No Medical Treatment � Other : ___________________________________________

Was a panel of physicians offered?

Who referred the employee for treatment?

Does the employee need a medical provider?

Was the employee transported by ambulance?

Did the employee go to a clinic / hospital when the injury occurred?

Name of clinic / hospital:

Has the employee been prescribed any medications?

Has the employee returned to work? On what date?

Return to work Status � Light Duty � Modified Duty � No Duty � Released to regular duty

6. Loss Description: � Fatality � Hospitalization � Medical Treatment � First aid case � Lost time � No Lost time

7. Submitted By:

Name : Title:

Signature:

STOP! DID YOU REMEMBER TO ATTACH THE FOLLOWING? � Employee Statement � All accident related medical documents

� Witness Statement (s) � Accident scene / job site photos

� Supervisors incident report � Waiver of medical treatment

NOTIFY HIRE QUEST LLC OF THE ACCIDENT IMMEDIATELY! FAX THIS REPORT & ATTACHMENTS TO 843-577-5742 A.S.A.P