Action Form - Accident/incident Analysis
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Accident/Incident Analysis: a step-by-step approach that simplifies the analysis process
Company: ____________________________
Department: __________________________
Supervisor: _______________________________
Employee: ____________________________
Job title: _____________________________
Date hired: ________________________________
Date/time of incident: ___________________
Date/time reported: ____________________
Incident location: ___________________________
Witnesses: ____________________________
Incident/near miss
Accident
First Aid
*File 801 if these
*Medical care
*Time loss
*Fatal
boxes are checked
Describe accident/incident:
A-C-T-I-O-N
Establishing accident analysis procedures are not only required, but also beneficial to your business. Having a process in place will allow
you to recognize the contributing factors involved and prevent future injuries. In order to simplify the analysis process, here is an approach
using six easy ACTION steps. Each step requires action, either by the employer or safety committee members.
A
ccident/incident
Is the hazard sufficiently controlled
Protect tools and
scene preservation
to prevent further injury?
equipment from
Yes
No
N/A
being relocated.
This is the beginning of your
Was first-aid provided to ensure
analysis. Your primary goal
well being of injured employee?
Yes
No
N/A
is to secure the scene. The
scene must be secured as
Is the scene secured to protect
soon as possible in order to
clues for analysis purposes?
Yes
No
N/A
preserve critical
physical clues.
C
Document your
ollect the facts
observations. Take
Focus on finding the
photos and check
video surveillance
facts about the event.
if available.
Remember to gather
valid information without
Interview
employees and
drawing conclusions or
witnesses.
assigning blame.
Review relevant
records, such as
maintenance,
training, policies,
procedures, etc.
T
rack sequence
Document
of events
what happened
before, during
Review the information
and after the
gathered and determine
event.
the series of events.
Reconstructing an
Arrange this
information
accurate timeline is
to accurately
critical to conducting an
determine the
effective analysis.
order of events.
OSHA requirements: On-the-job fatalities and catastrophes must be reported to Oregon OSHA within eight hours.
Report any accident that results in overnight hospitalization within 24 hours to Oregon OSHA.
Call 800.922.2689, 503.378.3272, or Oregon Emergency Response, 800.452.0311, on nights and weekends.
S924 SAIF Corporation 10/11
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