Form Sd1305 - 5 - Fdjj Accident Investigation Page 2
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2SD 1305 - 5
INSTRUCTIONS
I.
Date of Injury
Indicate the date the injury was incurred.
Time
Indicate the time of day the injury was incurred.
Date Reported
Indicate the date the injury was reported to management.
Exact Location
Give the exact location in the work area where the injury/accident occurred.
Body Part Injured
Indicate the body part that was injured in the accident. Examples include but are not limited to, toes, feet,
ankles, legs, knees, buttock, torso, shoulder, arm, elbow, hand, finger, neck, back, head, face.
Be specific with this description. Indicate left or right, etc. You are not limited to the body parts listed.
Type of Injury
Describe the type of injury received. Examples include, but are not limited to, sprains, strains,
cuts/laceration, fractures contusions, amputations, burns.
Be specific with this description. Your are not limited to the types of injuries listed.
Describe accident, what happened
Provide a short description of the accident according to information received as a result of conducting an
accident investigation, interviews with the injured employee, witnesses, etc.
Witness
List any witnesses to the accident/injury.
II
First Aid Only
Check "yes" or "no" as appropriate.
Doctor Visit Required
Check "yes" or "no" as appropriate.
III. Unsafe Acts
Unsafe acts are typically characterized by a deviation from standard job procedures and/or direct violation of Department safety rules/regulations.
Examples include, but are not limited to:
•
Operating tools/equipment without authority.
•
Operating tools/equipment at unsafe speeds.
•
Making safety devices inoperative.
•
Using unsafe equipment/tools.
•
Using equipment/tools unsafely.
•
Unsafe loading/material handling.
•
Taking unsafe position/posture.
•
Horseplay.
•
Failure to use personal protective equipment.
Unsafe Conditions
Unsafe conditions are typically characterized by the physical status of tools, equipment or work environment that increases the likelihood of an
accident occurring. Examples include, but are not limited to:
•
Sharp edges.
•
Defective tools/equipment.
•
Hazardous arrangement of tools, equipment, work environment.
•
Unsafe illumination.
•
Unsafe clothing.
•
Slippery floors.
IV.
Based on information provided above (unsafe acts/unsafe conditions) what action has been taken or recommended to management to prevent
reoccurrence:
Provide your opinion as to what could be done to prevent similar type injuries.
V.
Investigated By
Name of the person completing the Accident Investigation Form.
Title/Department
Title and Department of the person completing the Accident Investigation Form.
Date:
Date the Accident Investigation Form was completed.
VI.
Safety Director's Comments:
Provide general statements relative to the injury incurred, accident investigation, causes, recommendations, etc. If appropriate, provide additional
recommendations and/or actions that could be taken to prevent reoccurrence of similar type injuries.
Follow-up Action: Description of actions taken to see that recommendations designed to prevent reoccurrence has been completed within
a reasonable time period.
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Parent category: Business