14 Mill Park Court Newark, DE Office: Fax: Time:

Transcription

1 FIRST REPORT OF INCIDENT PERSONAL INJURY WC PROJECT DATA PERSONAL DATA Date of Incident: Date of Report: Project Manager: 14 Mill Park Court Time: or PM AM Day of Week Time of Report: or PM Project No.: Superintendent/Asst. Supt.: SITE Code : If Yes, List s: Drug Screen (s) Administered: Y or N Are There Any Witnesses? Y or N Type of Incident: circle type Name: Home Address: Occupation/Job Title: Time Started Work: Onsite First Aid Given: Y or N Offsite Medical Treatment: Y or N Date Treatment Given: Shade the Specific Body Part (s) Injured: Total Number of Witnesses: WC GL Auto Equip SS#: Years Experience: Bld Risk Property Date of Birth: Date of Hire: AM or PM Employment Status: (circle) FT PT TEMP SEASONAL If Yes, by Whom: If Yes, Treating Facility: Treating Facility INCIDENT TRACKING Body Part: Activity: Injury: Cause: Detailed Description of Injury: AM See Page 4 for Witness Instructions Near Miss CIRCLE Male / Female Married / Single List PPE worn at the time of the incident: Incident Designation: First Aid Only Non Recordable Medical Treatment Recordable Medical Treatment Preliminary Report Final Report Restricted Work Recordable - Lost Time Claim Denied

2 PAGE 2 GENERAL LIABILITY Name of Injured/ Property Owner: Injured/ Property Owner Address: Estimated Damages: Detailed Description of Damages: (draw a diagram on page three) Unit Description: Equipment Number: Rental: Y or N If yes, Rental ID#: Rented From: Rental Company Estimated Damage: Did Operator/Driver obey all applicable safety rules or D.O.T. Motor Vehicle Laws? Y or N If NO, list exceptions: AUTO & EQUIPMENT Did Authorities Respond (fire, police, ambulance, etc)? Y or N Was there Other Vehicle or Property Damage: Y or N For Auto Damage, Shade the Specific areas damaged: Responding Authority: Contact Person: Owners Name: License NO. & State:

3 PAGE 3 DESCRIPTION OF INCIDENT Describe in detail the circumstances of the incident. Give a chronological sequence of events. If materials, equipment and/or vehicles were involved, start before they were brought to the incident scene and describe the who, what, where when, and how the incident happened in your words below (specifically detail who, what, where, when, how, and why you believe the incident happened): (Show position and any relative distances of employee(s), vehicle(s), equipment, pedestrians, property, etc., and indicate an arrow of direction for each if travel or moving equipment was involved): DIAGRAM OF INCIDENT

4 PAGE 4 WITNESS STATEMENT: Attach Witness Statements on Incident Witness Statement Form Did the Job Hazard Analysis discuss the potential for this incident, and the safe work procedures to be followed to prevent it? YES or NO. Please attach a copy of either document to support your findings. What was the Root Cause(s) of the Incident? LESSONS LEARNED Contributing Factor(s) to the Incident: (weather, lighting, traffic control plan, communication of hazards, etc.) Corrective Action(s)That Where Taken to Prevent Reoccurrence: Participants in the Incident Analysis Management Review Name/Title or Trade Date Name Date Signature: Signature:

5 WITNESS FORM EMPLOYEE / WITNESS STATEMENT FORM SS # - - (Please Print) Witness Employer / Company: Employer Phone #: Witness Address: Work Home Date and Time of incident: am/pm List other Witnesses: Supervisor Notified on Date and Time: am/pm This is what happened (include who, what, where, when, how and why): Do you recall anything unusual or unexpected that happened? Yes or No If Yes Explain: Are there work conditions that contributed to this injury? Yes or No If Yes Explain: How would you prevent this incident from happening in the future? PLEASE USE AND ATTACH ADDITIONAL PAGES IF NECESSARY Witness Signature: Date: Company Representative Initiating Witness Report: Date: