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Plant Incident Report
Type of Incident
Injury
Incident
Both Injury and Incident
Employee Information
Name
DOB
Work phone
Personal phone
Length of employment
Time on current job
Injury Type (Check all that apply)
Strain/sprain
Fracture
Laceration/cut
Bruising
Scratch/abrasion
Amputation
Burn/scald
Dislocation
Internal
Foreign body
Chemical reaction
Other (specify)
No Injury
Property Damage
Property/material damaged
Nature of damage
Approximate cost of damage
Object/Substance inflicting damage
Incident
Brief incident description
Potential risk ranking
Very Serious
Serious
Minor
Chance of similar events happening?
Frequently
Occasionally
Rarely
What were the immediate causes of the accident?
What are the basic causes that led to this incident (i.e. the root cause)?
Conclusions/Impressions
What action has or will be taken to prevent a recurrence? (By? When? Actual?)
Treatment
Type of treatment given
Treating physician
Clinic location
Incident investigated by
Supervisor
OSHA recordable?
Yes
No
Event and Cause Checklist
Check all applicable events
Struck against
Struck by
Fall from elevation
Fall on same level
Caught in
Caught on
Caught between
Abnormal operation
Product contamination
Overstress, overpressure, overexertion
Equipment failure
Equipment release
Contact with (check all that apply)
Electricity
Heat
Cold
Radiation
Caustics
Toxic substances
Biological agents
Noise
Immediate or Direct Causes
Substandard Behaviors (check all that apply)
Operating equipment without authority
Failure to warn
Failure to secure
Operating at improper speed
Making safety devices inperative
Using defective equipment
Failure to use personal protective equipment (PPE) properly
Improper loading
Improper placement
Improper lifting
Improper position for task
Servicing equipment in operation
Horseplay
Under influence of alcohol and/or other drugs
Using equipment improperly
Failure to follow procedure
Failure to identify hazard/risk
Failure to check/monitor
Failure to react/correct
Failure to communicate/coordinate
Substandard Conditions (check all that apply)
Inadequate guards or barriers
Inadequate or improper protective equipment
Defective tools, equipment, or materials
Congestion or restricted action
Inadequate warning system
Fire and explosion hazards
Poor housekeeping/disorder
Noise exposure
Radiation exposure
Temperature extremes
Inadequate or excessive illumination
Inadequate ventilation
Presence of harmful materials
Inadequate instructions/procedures
Inadequate information/data
Inadequate preparation/planning
Inadequate support/assistance
Inadequate communications hardware/software/process
Road conditions
Weather conditions
Mind off task
Other - Describe
Root/Basic Causes
Personal Factors (check all that apply)
Physical capability
Mental/psych. capability
Physical stress
Mental stress
Lack of knowledge
Lack of training/skill
Improper motivation
Abuse or misuse
Job Factors (check all that apply)
Leader/supervision
Inadequate engineering
Improper maintenance
Improper tools/equipment
Excessive wear/tear
Poor communication
Poor housekeeping
Other - Describe
Submit
