First Report of Incident
Type of Incident/Near Miss/Regulatory Interaction (Select all that apply):
Date of incident/Event:
-
Month
-
Day
Year
Date
Time of incident/Event:
Hour Minutes
AM
PM
AM/PM Option
Location of Incident/Event:
Include Customer/Facility/Specific Location Address or Highway and mile marker information
Responsible Branch:
Please Select
Appleton
Asheville
Chicago
Chillicothe
Cincinnati
Dayton
Dearborn
Delta
Dundee
EMR
Hoosier
Indianapolis
Johns Manville
Loudon
Loudon EMR
Miami Fort
Middletown
Monroe
Moscow
Owensboro
Peoria
ES - Bellefontaine
ES - California
ES - Cincinnati
ES - Covington
ES - North Carolina
ES - Raymond
ES - Tennessee
Tate & Lyle - Decatur
Tate & Lyle - Lafayette
Tate & Lyle - Loudon
Three Rivers
Toledo
Toledo EMR
Travel Team (Ashland)
Travel Team (Indy)
Waterloo
Other
Other Branch
Person completing this report
Name of Supervisor
Supervisor's Contact Information
Please enter a valid phone number.
Name of Person Involved:
Person's statement
Number of witnesses
Please Select
0
1
2
3
Name of Witness (Click the "+" to add more witnesses):
Witness' Contact Information (Click the "+" to add more witnesses):
Witness 1 Statement
Witness 2 Statement
Witness 3 Statement
Severity Matrix
Severity of Incident
Please Select
1
2
3
4
Description of the Incident/Event:
Injury Type:
Mechanism of Injury:
Part of Body Injured:
Was the injured person taken to a medical facility?
Please Select
Yes
No
Name of medical facility
Address of medical facility
Phone Number of medical facility
Please enter a valid phone number.
Infraction of Policy or Procedure Type:
Regulatory Agency Involved:
Please Select
ATF
DOT
EPA
Fire Department
OSHA
Police
Other
Name of Agent:
Agent's Contact Information
Expected Agency Follow Up?
Materials involved in Fire/Reaction
Type of Material Released:
Please Select
Gas
Liquid
Sludge
Solid
Amount of Material Released (Estimated if appropriate):
Units of Measure of Release:
Please Select
Gallons
Ounces
Pounds
Tons
Cubic Feet
Cubic Yards
Was Material Released a Hazardous Waste?:
Yes
No
Unknown
Did release exceed an RQ for the material?:
Yes
No
NA
Was Hazardous Waste in Transportation?:
Yes, being loaded into transporter
Yes, traveling in transporter
Yes, being unloaded from transporter
No
Proper Shipping Information of Material:
Area Impacted by Release/Spill:
Property Damaged in Event: (Select all that apply)
Description of Property Damage:
Description of Items Involved in Theft:
Estimate of Value of Item(s) Involved in Theft:
Description of Items Involved in Vandalism:
Estimate of Value to Repair Vandalism:
Unit Number of Company Vehicle Involved in Collision/Accident:
Other Item Involved in Collision/Accident: (Select all that apply)
Description of Vehicle Collision/Accident:
Significant Outcome of Vehicle Collision/Accident:
Did the Employee Submit to a DOT(Drivers Only) Drug and Alcohol Post-Incident Test?
Please Select
Yes
No
Did the Employee Submit to a Non-DOT Drug and Alcohol Post-Incident Test?
Please Select
Yes
No
Police Report #:
Other Party Involved in Vehicle Collision/Accident (Click the "+" to add parties):
Other Party Involved in Vehicle Collision/Accident Contact Information (Click the "+" to add parties)
Has the Management Team Investigation (MTI) Been Conducted?:
Yes
No
MTI Lead:
MTI Participants (Click "+" to add participants)
Root Cause #1 Category
Please Select
Operating Equipment Without Authority
Failure to Warn
Failure to Secure
Operating at Improper Speed
Making Safety Devices Inoperative
Using Defective Equipment
Failing to use PPE Properly
Improper Loading
Improper Placement
Improper Lifting
Improper Position for Task
Servicing Equipment in Operation
Horseplay
Under the Influence of Drugs or Alcohol
Using Equipment Improperly
Inadequate Barriers or Guards
Inadequate or Improper Protective Equipment
Defective Tools, Equipment, or Materials
Congested or Restricted Actions
Inadequate Warning Systems
Fire & Explosion Hazards
Poor Housekeeping
Noise Exposure
Chemical Exposure
Temperature Extremes
Distractions
Lack of Training
Failure to Follow Procedures
Failure to identify hazard
Poor Decision
Root Cause #1 Information
Root Cause #1 Corrective Action Category:
Please Select
Policy or Procedure Review and Revision
Management Training
Inspections Instituted or Increased
Hazard Analysis Instituted or Revised
Emergency Preparedness Updated
Employee Training/Retraining
PPE Requirements Reviewed or Revised
Engineering Control Instituted or Revised
Group/Personal Communications
Disciplinary Action
Root Cause #2 Category
Please Select
Operating Equipment Without Authority
Failure to Warn
Failure to Secure
Operating at Improper Speed
Making Safety Devices Inoperative
Using Defective Equipment
Failing to use PPE Properly
Improper Loading
Improper Placement
Improper Lifting
Improper Position for Task
Servicing Equipment in Operation
Horseplay
Under the Influence of Drugs or Alcohol
Using Equipment Improperly
Inadequate Barriers or Guards
Inadequate or Improper Protective Equipment
Defective Tools, Equipment, or Materials
Congested or Restricted Actions
Inadequate Warning Systems
Fire & Explosion Hazards
Poor Housekeeping
Noise Exposure
Chemical Exposure
Temperature Extremes
Distractions
Lack of Training
Failure to Follow Procedures
Failure to Identify hazard
Poor Decision
Root Cause #2 Information
Root Cause #2 Corrective Action Category:
Please Select
Policy or Procedure Review and Revision
Management Training
Inspections Instituted or Increased
Hazard Analysis Instituted or Revised
Emergency Preparedness Updated
Employee Training/Retraining
PPE Requirements Reviewed or Revised
Engineering Control Instituted or Revised
Group/Personal Communications
Disciplinary Action
Root Cause #3 Category
Please Select
Operating Equipment Without Authority
Failure to Warn
Failure to Secure
Operating at Improper Speed
Making Safety Devices Inoperative
Using Defective Equipment
Failing to use PPE Properly
Improper Loading
Improper Placement
Improper Lifting
Improper Position for Task
Servicing Equipment in Operation
Horseplay
Under the Influence of Drugs or Alcohol
Using Equipment Improperly
Inadequate Barriers or Guards
Inadequate or Improper Protective Equipment
Defective Tools, Equipment, or Materials
Congested or Restricted Actions
Inadequate Warning Systems
Fire & Explosion Hazards
Poor Housekeeping
Noise Exposure
Chemical Exposure
Temperature Extremes
Distractions
Lack of Training
Failure to Follow Procedures
Failure to identify hazard
Poor Decision
Root Cause #3 Information
Root Cause #3 Corrective Action Category:
Please Select
Policy or Procedure Review and Revision
Management Training
Inspections Instituted or Increased
Hazard Analysis Instituted or Revised
Emergency Preparedness Updated
Employee Training/Retraining
PPE Requirements Reviewed or Revised
Engineering Control Instituted or Revised
Group/Personal Communications
Disciplinary Action
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Incident Closed
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