Supervisor Incident Investigation Report

SUPERVISOR INCIDENT INVESTIGATION REPORT INSTRUCTIONS: Begin investigation within twenty-four (24) hours and document by completing Supervisor Incident Investigation Report sections. Forward completed Supervisor Incident Investigation Report, Employee Incident Report and witness statements within three (3) working days to the Environmental Health and Safety (EHS) office (EHS building, Fax 75302 or [email protected]). Employee Name: Employee ID/800 #: Department: Standard Work Time: (from) (to) Incident Time: AM or PM Date of Incident: Supervisor: Supervisor Phone #: Incident Classifications (check all that apply): Near Miss Injury Health Exposure Fatality Spill Property Damage Other:

Employee Medical Treatment: No Medical Treatment First-Aid Only Medical treatment and released Hospitalized Other:

Employee Work Status: Returned to work no restrictions Returned to work with restrictions Did not return to work (Lost Days)

Names of Witnesses Interviewed:

INCIDENT INFORMATION: Describe the specific activity the employee was engaged in and the sequence of events. Include objects or substances that directly injured or made the employee ill. Describe tools, equipment, and personal protective equipment (PPE) used. Attach pictures of incident location and/or property damage and/or police reports.

Yes Yes

Is the activity part of the No Prior to beginning activity, did the employee No Date employee last received employee’s normal job? review potential hazards/dangers? training for the activity. CAUSE OF INCIDENT: Uneven surface Elevated work Violence or injuries caused by people or animals

Transportation Fires or Explosions Exposure to harmful substances or environment

Over-Exertion (lifting) Bodily Motion (reaching, twisting, running)

Contact with objects or equipment (Struck By, Struck Against, Caught-on, Caught between, Puncture, Cut)

Other (List Here):

What were the additional CONTRIBUTING FACTORS that caused the incident (See Investigation Examples)? Responsible RP Notified Status (Open Corrective Actions By When? Person (RP) (yes/ no) or Closed)

Supervisor’s Name: Signature Date of Report: / /

Manager’s Name: Signature Date Reviewed: / / The Supervisor will obtain the Manager’s signature and forward signed copies of the Employee Incident Report, Witness Statements and the Supervisor’s Incident Investigation Report to the EHS office. The EHS office will evaluate all reports, process claim information, verify corrective actions and analyze incident causes.

INVESTIGATION EXAMPLES CONTRIBUTING FACTORS CORRECTIVE ACTION EXAMPLES

Lack of Policies and Procedures Supervisor will consult with management and EHS

Lack of Policies and Procedure Training Supervisor will consult with management and EHS

Supervisor will verify training records and determine the appropriate Failure to Follow Policies and Procedures After Being Trained Human Resources action

Inadequate Policies, Procedures and Training For Job Task Supervisor will consult with management, EHS and Human Resources

Supervisor will establish temporary safety solution to remove the hazard, Failure to Recognize, Report and Avoid Hazards retrain employee and establish safety job site reviews Supervisor will review with Human Resources to evaluate job performance Lack of Professional Technical Knowledge and technical training requirements Supervisor will review EHS training requirements and ensure employee Lack of Environmental, Health and Safety Training receives the appropriate training Supervisor will review job task, procedures and make necessary Distracted or Unexpected Movement professional judgement on corrective action Not Wearing Appropriate Personal Protective Equipment Supervisor will review PPE information. If information is unclear (PPE) supervisor will consult with EHS. Supervisor will purchase adequate PPE and conduct a documented PPE Inadequate departmental review of PPE availability, use and storage

Improper Positioning or Repetitive Motion Supervisor will consult with EHS

Supervisor will purchase adequate tools and conduct a documented Improper/Inadequate Tool Use departmental review of tools availability, use and storage Supervisor will review the incident location and using objective Materials Not Secured professional judgement determine the corrective action measure Supervisor will enter a work request in Facilities Management’s Archibus Walking/Working Surface Hazards system or establish better lighting standards Supervisor will ensure the work space is clean, organized and free from Congested or Poorly Maintained Work Space recognized hazards as soon as possible Supervisor will enter a work request in Facilities Management’s Archibus Inadequate Lighting system or establish better lighting standards

Equipment Failure Supervisor will consult with EHS, and repair or purchase new equipment

Supervisor will review job task, procedures and make necessary Lack of Awareness professional judgement on corrective action

Supervisor Failure Consult with EHS

Management Failure Consult with EHS