Supervisors Accident Investigation Report

Supervisor’s Accident Investigation Report (To be completed within 24 hours of an accident)

1. DIVISION: Name & Address: ______Location of accident: ______County: ______

2. NAME OF INJURED EMPLOYEE: _____ Home phone No: ( ) Employee’s home address: Sex : M F - S.S. No Date of birth:

Date of Hire: ______Time of service: Years Weeks Time at present job: Years Weeks Title/Occupation (at time of injury):

3 DATE OF ACCIDENT: Time of accident: AM PM. Time shift started: AM PM. Date reported to supervisor: No. of workdays in the week: Scheduled hours (day):

4. SEVERITY OF INJURY: First Aid treatment Medical treatment Lost time Modified duty Fatality Estimated days away from work: Estimated days modified work: Date returned to work: Date returned to work: ______- -

5. DESCRIPTION OF INJURY: Part or parts of body affected (e.g.: HEAD, ARM, NECK, BACK, LEG): Nature of injury (e.g. FRACTURE, SPRAIN, LACERATION): 6. MEDICAL INFORMATION: Dr.’s Name: Address: Phone No.: ( ) Hospital's name: Phone No.: ( ) Address:

7. ACCIDENT DESCRIPTION: What directly caused injury / illness? Describe fully the conditions contributing to the accident / injury / illness (what happened?):______

Were conditions safe at time of incident? (physical, environmental, mechanical) Yes No (explain)

Employee’s work activity at time of accident:

Equipment involved: Manufacturer: Model No:

8. PERSONAL PROTECTIVE EQUIPMENT: (eye protection, safety shoes, hard hat, etc.)

Was employee using required safety equipment? Yes No Date employee was last trained in proper use of safety equipment: Was there a violation of a company safety & health rule, regulation, procedure or specific instructions? Yes No (Explain)

9. TRAINING: Was employee properly instructed on how to do the job safely? Yes No (Explain)

Were instructions adequately related as to the specific hazards involved? Yes No (Explain)

NPCA Guide to Plant Safety 7/23/02 Supervisor’s Accident Investigation Report (To be completed within 24 hours of an accident)

10. CORRECTIVE ACTION: What action should be taken to avoid a reoccurrence of this type of injury? (State: who, what, engineering changes, written procedure, development of improvement, enforcement of safety rules, regulations, procedures or specific training)

Action taken to correct and/or eliminate the hazards?

11. NAME OF WITNESS Witness home phone no: ( ) Witness statement of accident::

Date Report Prepared:

I do I do not feel medical attention is required at this time.

(Employee Signature) ( Date)

(Signature of Superintendent / Project Manager) (Date)

Is this incident MSHA/OSHA reportable? YES z NO z Were the 7000-1 (MSHA) or 200 Log (OSHA) entries made? YES z NO z If only first aid administered, complete 1 – 5 and 7. YES z NO z

TO REPORT AN ACCIDENT CALL:

1-(xxx) xxx-xxxx

INSURANCE CARRIER:

Claim Contact: Reference/Claim # Assigned: Site Code: MSHA ID Number:

NPCA Guide to Plant Safety 7/23/02 Supervisor’s Accident Investigation Report (To be completed within 24 hours of an accident)

WORK ACCIDENT, INJURY AND ILLNESS QUESTIONNAIRE

PLANT NAME: ______PLANT NUMBER: ______

DATE OF ACCIDENT, INJURY or ILLNESS: ______

EMPLOYEE NAME: ______

W/C CLAIM NUMBER: ______

DID THE ACCIDENT, INJURY OR ILLNESS RESULT IN ANY OF THE FOLLOWING?

Can the treatment administered for the injury be described as: YES NO

. Using a non-prescription medication at non-prescription strength. ______. Administering tetanus immunizations. ______. Cleaning, flushing or soaking wounds on the surface of the skin. ______. Using wound coverings such as bandages, Band-Aids™, gauze pads, etc.; or using butterfly bandages or Steri-Strips™. ______. Using hot or cold therapy. ______. Using any non-rigid means of support, such as elastic bandages, wraps, non-rigid back belts, etc. that does not contain rigid stays or other systems designed to immobilize parts of the body. ______. Using temporary immobilization devices while transporting an accident victim (e.g., splints, slings, neck collars, backboards, etc.). ______. Drilling of a fingernail or toenail to relieve pressure, or draining fluid from a blister. ______. Using an eye patch. ______. Removing foreign bodies from the eye using only irrigation or a cotton swab. ______. Removing splinters or foreign material from areas other than the eye by irrigation, tweezers, cotton swabs or other simple means. ______. Using finger guards. ______. Using massages, but not physical therapy or chiropractic treatment. ______. Drinking fluids for relief of heat stress. ______

This list is all-inclusive for first aid treatment. When describing the treatment administered for the injury, if all of the above are marked “No,” then the treatment is considered to be medical treatment and the incident must be reported. Should you have questions regarding incidents not covered above, please refer to Part II/III, Accident Recording and Reporting -- “Guidelines for Reporting of MSHA/OSHA Incidents” of the Safety and Health Compliance Advisory or contact your respective Safety Department.

NPCA Guide to Plant Safety 7/23/02 Supervisor’s Accident Investigation Report (To be completed within 24 hours of an accident) Incident Information Form

Date: Time: Location: Employee Name: Address: City: State: Zip: Home Phone:

Written description of Incident: (Diagram on reverse side). ______Police Dept. Notified: Phone #: Officer’s Name: Badge #:

Unit #1: Description Name of Driver: Address: City: State: Zip: Home Phone #: Work Phone #: Auto Year: Make: Model: Color: License #:

Insurance Information: Company’s Name: Policy Number: Agent’s Name: Agent’s Phone #:

Unit #2: Description Name of Driver: Address: City: State: Zip: Home Phone #: Work Phone #: Auto Year: Make: Model: Color: License #:

Insurance Information: Company’s Name: Policy Number: Agent’s Name: Agent’s Phone #:

Injuries: Name: Address: City: State: Zip: Home Phone #: Work Phone #: Description of injury: Was medical treatment received?:

Name: Address: City: State: Zip: Home Phone #: Work Phone #: Description of injury: Was medical treatment received?:

Property Damage: Owner’s Name: Address: Home Phone #: Work Phone #:

NPCA Guide to Plant Safety 7/23/02 Supervisor’s Accident Investigation Report (To be completed within 24 hours of an accident) Description of Damage: ______

Witness: Name: Address: City: State: Zip: Home Phone #: Work Phone #:

Name: Address: City: State: Zip: Home Phone #: Work Phone #:

Please show location of cars involved in accident.

Show names of streets or roads and, if possible, the points of the compass.

(Make multiple copies if needed.)

NPCA Guide to Plant Safety 7/23/02