Provided by
(Client Name) (Client Address)
(Applies to all Company locations)
Risk Department
TITLE
ACCIDENT/INCIDENT INVESTIGATION & REPORTING ACCIDENT/INCIDENT REPORTING
TABLE OF CONTENTS
1. PURPOSE...... 3 2. REFERENCES...... 3 3. ENCLOSURES...... 3 4. RESPONSIBILITIES...... 3 5. DEFINITIONS...... 4 6. PROCEDURE...... 4 CBR Injury Report Form...... 7 Employee’s Injury Report Form...... 8 Critical Incident Report...... 10 Critical Incident Investigation Checklist...... 18
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1. PURPOSE
1.1. To thoroughly document every accident/incident for the purpose of:
1.1.1. Providing a safer work environment as a result of follow up indicated in reports of accidents/incidences.
1.1.2. Protecting company interests against charges brought about by injured employees, governmental authorities and other entities.
2. REFERENCES
2.1. 29 CFR 1904: Recording and Reporting Occupational Injuries and Illnesses
2.2. 29 CFR 1910.151: Medical Services and First Aid
3. ENCLOSURES
3.1. CBR Injury Report Form (Supervisors)
3.2. Employee’s Injury Report Form
3.3. Critical Incident Report
3.4. Witness Interview Form
4. RESPONSIBILITIES
4.1. The Supervisor/Foreman/Safety Coordinator
4.1.1. Complete and submit the CBR Injury Report form within the prescribed timeframe in each procedure.
4.1.2. Designate the appropriate contact person for follow up by CBR personnel or claim administrators.
4.2. Each employee involved in an accident/incident
4.2.1. Complete and submit the CBR Employee’s Injury Report form within the prescribed timeframe in each procedure.
4.2.2. Submit to injury protocols as established in the following procedures.
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4.3. The CBR Injury Counselor
4.3.1. File all reports with respective state agencies and insurance carriers.
4.3.2. Track all workers comp claims through closure.
4.3.3. Communicate work status information to the injured employee and the appropriate contact person at CBR.
5. DEFINITIONS
5.1. Incident: an unexpected occurrence which interferes with the orderly progress of work and which caused, or might have caused, one or more of the following:
5.1.1. An injury, illness or adverse effect on the health of one or more employees.
5.1.2. Significant loss of physical facilities even though potential for injury was small.
5.1.3. An event or condition that did or could have impacted the environment.
5.1.4. A situation that could have an unfavorable impact on the public.
5.2. Investigation Facts: a listing of key facts that are the basis for the corrective action.
5.3. Corrective Action: a list of all recommendations the investigation team makes with the individual responsible for carrying out each recommendation.
5.4. Primary Cause: the primary factor or item involved that resulted in the incident.
5.5. Contributing Factor: additional factors that, if identified, could have avoided the incident or reduced the severity of the incident.
6. PROCEDURE
6.1. It is extremely important that all contributing factors of each incident are discovered during the investigation. The information obtained during the investigation will assist in correcting the conditions that produced the incident. The objective of investigating and reporting incidents is to prevent recurrence by:
6.1.1. Identifying and correcting hazardous conditions and practices through a detailed analysis of the incident.
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6.1.2. Promptly communicating the findings to others who may benefit from the specific information and understanding developed through the investigation.
6.1.3. Making broad application of the findings to update procedures and standard practices by all groups.
6.1.4. Providing information to achieve this objective. It is imperative that all investigations be performed completely and without bias so that all the facts and only the facts of the incident be determined.
6.2. Investigations are not conducted to find fault or place blame on employees.
6.3. Prerequisites
6.3.1. Injured employee’s supervisor completes the CBR Injury Report Form (See Enclosure 3.1) and submits to CBR.
6.3.2. Injured employee completes the CBR Employee’s Injury Report Form (See Enclosure 3.2) and submits to CBR.
6.3.3. Injured employee’s supervisor completes the CBR Critical Incident Report (See Enclosure 3.3) if any of the following are true of the incident:
6.3.3.1. More than one employee was injured in the same incident.
6.3.3.2. The injured employee was taken to a hospital for treatment.
6.3.3.3. The injured employee suffered a broken bone(s) or a severe cut (deep cut, tendon involvement or excessive bleeding).
6.3.3.4. The injured employee fell from a height greater than 6 feet.
6.3.3.5. The injured employee was involved in a trenching/excavation incident.
6.3.3.6. The incident involved damage to equipment or property.
6.3.3.7. The incident is considered “critical” for any other reason.
6.4. Incident Investigation
6.4.1. Every Critical Incident should be investigated, and investigation should happen promptly. The responsible foreman or manager shall assemble the investigation team as soon as possible after the incident.
6.4.2. The investigation committee will consist of one co-worker of the injured employee, the affected manager or designee and the Safety Coordinator.
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6.4.3. Establish facts of the case by interviewing the injured employee, witnesses and employees directly involved with the incident. Assess the incident scene for further facts.
6.4.4. Develop recommendations for corrective actions designed to prevent recurrence of the incident, including persons responsible for implementation of recommendations.
6.4.5. Evaluate initial actions taken by personnel.
6.4.6. Submit the Critical Incident Report to CBR.
6.5. Investigation Follow-up
6.5.1. A summary of the incident should be sent to all departments/crews who might benefit from the information. The information should include:
6.5.1.1. How the incident happened.
6.5.1.2. Causes of the incident.
6.5.1.3. Outcome of the incident (For example – two employees were taken to the hospital, one suffered a broken leg, the other received 20 stitches) (DO NOT provide personal information, only a description of the injuries and treatment.)
6.5.1.4. What is being done to avoid similar incidents and to keep other workers safe.
6.5.2. The incident summary should be the topic used during the next safety meeting.
6.5.3. This procedure will be re-evaluated annually, or as needed. Coordinate efforts with CBR to make necessary changes to this procedure.
6.5.4. This procedure will be directed by the Safety Coordinator.
Page 6 of 23 ACCIDENT/INCIDENT REPORTING ENCLOSURE 3.1
CBR INJURY REPORT FORM
PLEASE COMPLETE AND SUBMIT THIS FORM WITHIN 24 HOURS OF THE INCIDENT. Fax: 888-206-4537 Risk Department Phone: 602-200-8500 x2045 INJURY REPORT Notificación de accidente
Company: Branch: Policy #:
Name of Injured: Nombre de la persona lesionada
Soc. Sec# Age Married Yes No Occupation: No. de Seguro Social Edad Casado Ocupacion
Date of Accident: Time: AM PM Time Employee Started Work: AM PM Fecha del Accidente Nature of Injury: Right Left? Tipo de lesion Did injured leave work? Yes No Date: Time: AM PM Dejo el trabajo? Did injured return to work? Yes No Date: Time: AM PM Volvio a sus labores? Was injured acting in regular line of duty? Yes No Name of witnesses: Estaba la persona lesionada realizando sus labores regulares? Nombres de testigos What was he/she doing? Where did the accident occur? Donde sucedio el accidente? How did the accident occur? Como sucedio el accidente?
Type of machinery or tools being used: Tipo de maquinarias o herramientas implicadas Was the machinery/tool in good working order? Yes No If no, what was wrong with it?
What steps have been taken to prevent similar accidents? Como se ha tratado de prevenir accidentes similares?
Was the injured sent to a clinic? Yes No If yes, where? Fue a la clinica? Date: Supervisor’s Signature: Fecha Firma del Supervisor
Supervisor’s Phone: Supervisor’s Printed Name:
To be completed by a Supervisor El Supervisor tiene que llenar esta forma
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ENCLOSURE 3.2
EMPLOYEE’S INJURY REPORT FORM
Name: ______Date of Injury: ______Home Phone Number: ______Other Phone Number: ______
What type of injury/illness did you sustain? (Circle one or more) Abrasion (scrape) Contusion (bruise) Infection Sprain/strain Burn Dehydration Insect Bite Other: Cut Fracture Puncture
What caused the illness/injury? (Circle one or more) Equipment Malfunction Human Error (myself) Overexertion Exposure to Bodily Fluid Human Error (others) Repetitive Motion Exposure to Infection Lack of Safety Equipment Slip/Trip/Fall Falling Object Lack of Supervision Other: Faulty Equipment Motor Vehicle Accident
What body part was injured? (Circle one or more) Right or Left Head Shoulder Hand Abdomen Knee Other: Eye Arm Finger Lower Calf Nose Elbow Chest Back Ankle Ear Forearm Upper Hip Foot Mouth Wrist Back Leg Toe
What job/task were you doing when the injury occurred?
How did the injury occur?
Witnesses:
Was all equipment/machinery working properly? If not, what was wrong?
How could this injury have been avoided?
Questions about your injury? Contact CBR’s Injury Counselor at 602-200-8500 x2045.
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FORMA PARA EL EMPLEADO REPORTE DE LESION
Nombre: ______Fecha del lesion: ______Numero de Teléfono: ______Otro Numero de Teléfono: ______
Que tipo de lesión / enfermada usted sostuvo? (Circule una o mas) Raspadura (rasguño) Contusionar (moretón) Infección Pinchazo Quemadura Deshidratación Torcedura / esfuerzo Otro: Cortada Fractura Picadura de Insecto
Que causo la lesión / enfermada? (Circule una o mas) Equipo Mal Funcionado Accidente de Motor de Vehículo Exposición a Danos Corporales Human Error (propio) Resbalar / Tropezar / Caída Exposición a Infección Human Error (otros) Otro: Equipo Defectuoso Falta de Equipo de Seguridad Objeto Caído Falta de Supervisión
Que parte de su cuerpo se lesiono? (Circule una o mas) Derecha o Izquierda Cabeza Hombro Mano Abdomen Rodia Otro: Ojo Brazo Dedo Abajo de Pantorrilla Nariz Codo Pecho Espalda Tobillo Oído Antebrazo Arriba de Cadera Pie Boca Muñeca Espalda Pierna Toe
Que trabajo / tarea estaba haciendo cuando ocurrió la lesión?
Como ocurrió esta lesión?
Testigos:
Estaba el equipo / maquinaria trabajando correctamente? Si NO, que estaba mal?
Como se pudo haber evitado esta lesión?
Preguntas de su lesión? Contacte CBR’s Aconsejadora de Lesiones a 602-200-8500 x2045.
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ENCLOSURE 3.3
CRITICAL INCIDENT REPORT (To be completed by Injured Employee’s Supervisor)
Instructions
Complete this form if any of the following are true of this incident: 1. More than one employee was injured in the same incident. 2. The injured employee was taken to a hospital for treatment. 3. The injured employee suffered broken bones or a severe cut (deep cut, tendon involvement or excessive bleeding). 4. The injured employee fell from a height greater than 6 feet. 5. The injured employee was involved in a trenching/excavation incident. 6. The incident involved damage to equipment or property. 7. The incident is considered “critical” for any other reason.
Contact CBR Risk Management at 602-200-8500 x2012 immediately. Secure the area with caution tape or barricades and do not allow anyone other than the investigation team to enter the area. Do not move or remove anything from the area. Take photos of the accident scene and the surrounding area immediately. (There cannot be too many pictures. Shoot from every angle and at various zoom settings.) Identify and document: o General Contractor on the site o Sub-contractors on the site o All supervisory personnel from each contractor, including your own, on site Complete this report thoroughly. (If necessary, see more detailed investigation instructions following the Incident Investigation form.)
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CRITICAL INCIDENT REPORT
Report prepared by: ______Phone Number: ______CBR Client Name: ______Branch: ______Date of Incident: ______Date of Report: ______
Project Information: Jobsite Name: ______Job Number: ______Address: ______General Contractor: ______GC Superintendent: ______Sub-Contractor: ______Sub’s Superintendent: ______Foremen &/or Safety Rep’s on site: ______
Employee/Incident Information: (Supply this information for each injured employee.) Employee Name: ______SS#: ______DOB:______Address: ______Phone: ______Cell:______Job Title: ______Yrs in Occupation: ______Shift Start Time: ______End Time: ______Exact location of incident (Bldg/Level/Area): ______Specific activity at time of incident (ie – moving pipe): ______
Injury/Illness Information: Date of Accident: ______Day of Week: ______Time: ______Date Reported: ______To Whom? ______Type of Injury (ie – cut): ______Cause (ie – fall): ______Body Part(s) Injured: ______Right or Left? ______Was first aid given onsite? ______If yes, by whom? ______Was employee taken to a medical facility? _____ If yes, where? ______Transported by: Ambulance Company Vehicle Name of driver: ______Employee status: Fatality Hospitalization Modified Work If treated at a hospital or unauthorized medical facility, submit copies of all paperwork to CBR. Employee’s Supervisor: ______Phone: ______Was a Hazard Analysis used for the work being performed at the time of the incident? Yes No If yes, attach.
Incident Designations: (Check all that apply.) Fatality Multiple employees injured Treatment at a hospital Damage to equipment/property Broken bones or severe cut Fall from greater than 6’ Trenching/Excavation incident Other:
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Description of the Incident: (Not to be completed by the injured worker.) Describe in detail the circumstances of the incident. (Give a chronological sequence of events. If materials and/or equipment were involved, start before the materials/equipment were brought to the incident scene describing who, what, where, when, how.)
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Additional Information: Name of witnesses and others working with the injured worker (attach witness statements):
Object, substance, equipment involved in incident (description/model/serial #):
PPE worn at time of incident:
Safety equipment & training required for the job: (Attach documentation of training.)
Does the employee normally operate this equipment? Yes No Was employee instructed in the safe use of this equipment? Yes No When/how – Describe in detail and attach copies of equipment certifications.
Was any defect with the equipment noted or reported prior to accident/incident? Yes No Was any recent maintenance/service performed on this equipment? Yes No If yes, when/what – describe in detail.
Were standard work procedures followed? Yes No If no, why not? Describe, attach additional sheets if necessary and attach a copy of the standard site procedures.
Was a safety rule or specific instruction violated? Yes No If yes, what? Describe in detail, attach additional sheets if necessary and attach a copy of the rule/regulation.
When/how was this rule/regulation or specific instruction communicated to the injured worker(s)? Attach documented training and safety meetings.
Signatures Management: ______Print Name Signature Supervisor: ______Print Name Signature Foreman: ______Print Name Signature
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INJURED WORKER’S STATEMENT
I______, am submitting this statement on______. Injured Employee’s Name Today’s Date to for______. Supervisor/Company Representative Company I am submitting this statement of my own free will. I have not been coerced or threatened in any way to submit this statement.
Consider in your statement and write in the area below: What happened? Tell a story. Where were you when the incident took place? What activity was being performed prior to the event? What do you believe happened? Any other information or details.
Statement:
If you were injured in the incident, have you ever injured this body part before? Yes No
Employee signature: ______Today’s date: I have received a copy of this statement: Yes No Home Address:______Home Phone: ______Alternate Phone: ______
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DECLARACION DEL EMPLEADO LASTIMADO
Yo______, estoy sometiendo esta declaración el ______. Nombre del Empleado Lastimado Fecha de Hoy A ______por______. Supervisor/Representante de Compañía Compañía Estoy sometiendo esta declaración de mi propia voluntada. No he sido obligado o amenazado de ninguna manera para someter esta declaración por estrito.
Considere en su declaración y escriba en el área abajo: ¿Que paso? Cuente la historia. ¿Dónde estaba cuando ocurrió el incidente? ¿Qué actividad estaba haciendo antes del evento? ¿Qué es lo que usted cree que paso? Alguna otra información o detalles.
Declaración:
¿Si usted se lastimo esta herida, se ha lastimado antes esta parte del cuerpo? Si No
Firma del Empleado: ______Fecha de Hoy: ______Recibí una copia de esta declaración: Si No Dirección de Casa: ______Numero de Casa: ______Otro Numero: ______
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EMPLOYEE/WITNESS STATEMENT
I, ______, am submitting this statement on ______. Injured Employee’s Name Today’s Date to ______for ______. Supervisor/Company Representative Company
I am submitting this statement of my own free will. I have not been coerced or threatened in any way to submit this statement.
Consider in your statement and write in the area below: What happened? Tell a story. What do you believe went wrong? Where were you when the incident took place? Any other information or details. What activity was being performed prior to the event? Statement:
Employee/Witness signature: ______. Employee/Witness initials that they have received a copy of this statement: ______Today’s Date: ______Employer:______Home Address: ______Home Phone: ______Alternate Phone: ______
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DECLARACION DEL EMPLEADO / TESTIGO
Yo,______, estoy sometiendo esta declaración el ______. Nombre del Empleado Lastimado Fecha de Hoy A ______por ______. Supervisor/Representante de Compañía Compañía
Estoy sometiendo esta declaración de mi propia voluntad. No he sido obligado o amenazado de ninguna manera para someter esta declaración por estrito.
Considere en su declaración y escriba en el área abajo: ¿Que paso? Cuente la historia. ¿Qué cree usted que paso? ¿Dónde estaba cuando ocurrió el incidente? Alguna otra información o detalles. ¿Que actividad estaba haciendo antes del evento?
Declaración:
Firma del Empleado / Testigo: ______Iniciales del Empleado / Testigo que recibí una copia de esta declaración: ______Fecha de Hoy: ______Empleador: ______. Dirección de Casa: ______Numero de Casa: ______Otro Numero: ______
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ENCLOSURE 3.4
CRITICAL INCIDENT INVESTIGATION CHECKLIST
In the event of a Critical Incident, notify CBR immediately! CBR Risk Department: 602-200-8500 x2012 (cell: 602-459-1922)
Notify OSHA within 8 hours if the incident resulted in: Fatality Multiple (more than 2 employees) injuries requiring hospitalization
Notify OSHA of: Company name Location of incident Time of incident Number of fatalities or hospitalized employees Contact person Phone number Brief description of the incident
Gather documentation: Identify total hours for each employee for the previous 48 hours and the previous week Training records for all personnel on the job site All reprimands for personnel on the job site Copy of the Site-specific Health and Safety Program Develop a timeline detailing the crew/employees’ activities from the beginning of that day’s shift If the incident involved a motor vehicle accident, obtain DMV reports, vehicle use agreement and the most recent drug assay Conduct the same activities for sub-contractors, if any
Items Needed for Thorough Investigation: Camera Chalk Recording device Red spray paint Video camera String lines Clipboard Flashlight Notebook paper Tape measure (100 ft) Graph paper Nails Pens Hammer Plastic bags and envelops Barricade tape Aluminum foil Sharpee pen Paper towels
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Witness Interviews: (see “Witness Interview Form,” page 3 of Critical Incident Investigation Checklist)
Scene Criteria: Identify and record the position and location of: Injured/dead personnel Vehicles Equipment Material that may have affected the accident Broken or detached parts of equipment or material Objects that were broken, damaged or struck during or as a result of the accident Gouges, scratches, dents, paint smears, skid marks on surfaces, traces of movement, defects or irregularities in surfaces, stains from fluids (new and old), areas of debris Safety devices and equipment Sources of distraction and environmental conditions. Use tape to identify original position of items that have been moved.
Obtain pictures of incident area: General view (from all four sides) Approach view (if movement was a part of the incident activity Overhead view (if possible) Medium range view (major elements of the site) Articles of evidence (photograph before movement) Objects with direct impact to the accident (tools, blood stains, broken parts, fluid, etc) Take two pictures per item, close up and at 6’ from object. Lay a tape measure beside object to indicate exact size. Weather conditions (to indicate visibility, rain, snow, ice etc)
Diagrams: Use graph paper Note location of witnesses Diagram to scale Mark camera positions Use fixed precise points for reference Date the diagram Indicate items photographed or Title the area identified in interviews Obtain signature of investigation Label each item personnel
Accident Report: Detailed description of the accident (who, what, when, where, how) List of who was notified and when Documentation of who investigated the accident (company, OSHA, police, etc) Photographs Diagrams Witness statements Recordings Contract documents (rental agreements, hold harmless clauses, etc)
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Critical Incident Report All notes
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WITNESS INTERVIEW FORM
Interview witnesses separately, and at the job site, if possible. Record conversations, identify times and distances from the incident and other witnesses. This interview should be conducted verbally, and the witness should complete the Employee/Witness Statement form.
Name: ______Job Title: ______Address: ______Phone: ______Age: _____ Years Experience: _____ What do you know about the accident?
What did you see before, during and after the accident?
What did you hear before, during and after the accident?
What did you feel before, during and after the accident?
What did you do before, during and after the accident?
What time did the accident occur? Where did the accident occur? (Exact location)
What environmental factors were present?
Describe the exact position of every person and piece of equipment that you can remember before, during and after the accident.
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Was anything moved, repositioned, turned off or on or removed? If so, what, where and by whom?
What attracted witnesses’ attention?
What did responders do?
Describe as much information about the victim(s) as possible.
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