Wa Incident Report Form - Tremco
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2
3(CHECK THE APPROPRIATE BOX)
TYPE OF INCIDENT:
INJURY/ILLNESS
NEAR MISS
PROPERTY DAMAGE
INITIAL INCIDENT REPORT
OTHER (
)
BASIC
PROJECT NAME &
MEDICAL FACILITY
INCIDENT DATE:
INFORMATION
ADDRESS:
NAME & ADDRESS:
INCIDENT TIME:
FIRST AID
RESTRICTED/TRANSFERRED*
(CHECK THE BOX THAT BEST INDENTIFIES THE INJURY)
LOST TIME*
MEDICAL BEYOND FIRST AID*
RECORD ONLY
INJURY
OSHA RECORDABLE*
COMMENTS/CLARIFICATIONS
:
CLASSIFICATION
(OTHER)
N/A:
EMPLOYEE TREATED:
ON SITE
OFFSITE
(IF OFFSITE, PROVIDE TREATMENT LOCATION):
JOB TITLE:
NAME:
GENDER:
MALE
FEMALE
TIME SHIFT BEGAN:
TASK PERFORMING AT TIME OF INCIDENT:
:
LENGTH OF EXPERIENCE:
YEARS
MONTHS
(JOBSITE SPECIFIC)
INCIDENT LOCATION
EMPLOYEE
INVOLVED
TREMCO Orientation:
NO
YES
START DATE ON THIS JOB:
CONTACT NUMBER:
TREMCO HIRE DATE:
PAYROLL:
PART TIME
EMPLOYMENT STATUS:
FULL TIME
(Please Select One)
DIVISION & LOCATION:
(Please Select One)
WORK REGION:
CONTACT NUMBER:
SUPERVISOR NAME:
CONTACT NUMBER:
NAME:
WITNESS
STATEMENT PROVIDED?
YES
NO
INFORMATION
*
If OSHA Recordable, DART, or Lost Time Incident, Obtain Witness Statements and Attach Photos as Required
(CHECK ALL THAT APPLY)
(CHECK ALL THAT APPLY)
INCIDENT TYPE
INJURY/ILLNESS TYPE
01 - STRUCK BY
05 - SAME LEVEL FALL
09 - INHALATION
01 - ABRASION
05 - AMPUTATION
02 - STRUCK AGAINST
06 - FALL TO BELOW
10 - HEAT
02 - PUNCTURE
06 - BURN
07 - LIFTING/PUSH/PULL
03 - CAUGHT IN/ON
11 - OTHER (
)
03 - LACERATION
07 - FRACTURE
04 - CAUGHT BETWEEN
08 - ELECTRICAL
12 - N/A
04 - CRUSHING
08 - SPRAIN/STRAIN
(CHECK ALL THAT APPLY)
BODY PART AFFECTED
01 – HEAD
05 – BACK
09 – ARM
13 – LEG
INJURY/ILLNESS
02 – FACE
06 – CHEST
10 – HAND
14 – KNEE
INFORMATION
03 – EYE
07 – SHOULDER
11 – FINGER
15 – FOOT/ANKLE
04 – NECK
08 – ELBOW
12 – GROIN/HERNIA
16 – OTHER (
)
PROJECT STATUS
OTHER CONTRIBUTING FACTORS
(CHECK ALL THAT APPLY)
(CHECK ALL THAT APPLY)
WEATHER
BEHAVIOR
COMPRESSED SCHEDULE
GC
FIRST 10%
GS
HOUSEKEEPING
NOT COMPLIANT TO POLICY
LAST 10%
EXTENDED HOURS
BODY POSITIONING
LACK OF PREVENTATIVE MAINT.
FAULTY EQUIP./LACK OF INSPECTION
OFF HOURS WORK
SALES VISIT
LACK OF TRAINING
DESCRIPTION
OF
INCIDENT
ROOT CAUSES = WHY INCIDENT OCCURRED (IDENTIFY AT LEAST THE TOP 3)
ROOT
1.
(Please select the most appropriate 1st Root Cause of the incident)
CAUSE
2.
(Please select the most appropriate 2nd Root Cause of the incident)
3.
ANALYSIS
(Please select the most appropriate 3rd Root Cause of the incident)
4.
(Please select the most appropriate 4th Root Cause of the incident)
CORRECTIVE
SMART (Specific, Measurable, Achievable, Result-oriented, Time-bound)
ACTION BY
DUE DATE
CLOSED
ACTIONS
1.
-
2.
-
PLEASE ASSOCIATE
ACTIONS
3.
-
w/ ROOT CAUSES
4.
-
INJURED EMPLOYEE:
DATE:
DATE:
SUPERVISOR:
*SIGNATURES
REGIONAL/
TREMCO EHS REP:
DATE:
DATE:
PROJECT MGR:
*HUMAN
Submit By E-Mail
Print
WAGE RATE:
EMPLOYEE D.O.B:
RESOURCES
REV. 3 (3/2015)
S.S.N.
SECTION (ONLY)
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