Safety Investigation Report
City of Newport News
What type of incident are you reporting?
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Injury/Illness only
Vehicle/Property damage only
Vehicle/Property damage and Injury
Near miss
Date of incident
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-
Month
-
Day
Year
Date
Employee
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First Name
Last Name
Employee's age:
*
Employee's sex (assigned at birth):
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Male
Female
Employee Job Title
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Employee Department
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Please Select
BUDGET AND EVALUATION
CIRCUIT COURT
CITY ASSESSOR'S OFFICE
CITY ATTORNEY
CITY CLERK
CITY COUNCIL
CITY MANAGER
CLERK OF COURTS
CODES COMPLIANCE
COMMISSIONER OF THE REVENUE
COMMONWEALTH ATTORNEY
COURT SERVICES
DEPARTMENT OF COMMUNICATIONS
DEVELOPMENT
ENGINEERING
FINANCE
FIRE
GENERAL DISTRICT COURTS
GENERAL SERVICES
GENERAL SERVICES – GEN FUND
HUMAN RESOURCES
HUMAN SERVICES
INFORMATION TECHNOLOGY
INTERNAL AUDITOR
JUVENILE SERVICES
LIBRARIES
OFFICE OF RISK MANAGEMENT
PARKS & RECREATION
PLANNING
POLICE
PUBLIC WORKS
SECURITY SERVICES
SHERIFF
TREASURER
WATERWORKS
Employee's Date Hired
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-
Month
-
Day
Year
Date
Employee Supervisor
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First Name
Last Name
Supervisor Email
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example@example.com
Forward Copy To Email (Department Safety Officer or Representative)
example@example.com
Witness Information
Was there a witness?
Yes
No
Witness
First Name
Last Name
Witness Contact Info
Phone #
Email
Incident Location
Incident location
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Did this incident happen in a Traffic Control Work Zone?
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Yes
No
Injury Information
Was employee treated in an emergency room?
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Yes
No
Was employee hospitalized overnight as an in-patient?
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Yes
No
Time employee began work
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Hour Minutes
AM
PM
AM/PM Option
Time of incident
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Hour Minutes
AM
PM
AM/PM Option
What was the employee doing just before the incident occurred? Describe the activity as well as the tools, equipment, or material the employee was using. Be specific. Examples: "climbing a ladder while carrying roofing materials"; "spraying chlorine from hand sprayer"; "daily computer key-entry."
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0/0
What happened? Tell us how the injury or illness occurred. Examples: "When ladder slipped on wet floor, worker fell 20 feet"; "Worker was sprayed with chlorine when gasket broke during replacement"; "Worker developed soreness in wrist over time."
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0/0
What was the injury or illness? Tell us the part of the body that was affected and how it was affected; be more specific than "hurt," "pain," or "sore." Examples: "strained back"; "chemical burn, hand"; "carpal tunnel syndrome."
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0/0
What object or substance directly harmed the employee? Examples: “concrete floor”; “chlorine”; “radial arm saw.” If this question does not apply to the incident, leave it blank
Injured Body Part-Please add as many rows needed to identify all body parts impacted
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Near Miss Information
A near miss is an unplanned event that did not result in injury, illness, or property damage, but had the potential to do so.
Description of near miss incident.
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0/0
Contributing Factors
Identify conditions or factors that may have contributed to the incident.
Environmental / Site Conditions (Select all that apply)
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Confined or restricted space
Congested or constrained work area
Fixed object proximity / limited clearance
Noise or vibration levels
Obstructed walkways, access or work areas
Poor housekeeping
Poor lighting
Slippery or uneven walking/working surfaces
Weather conditions (rain, snow, ice, heat, wind)
Not applicable
Work Practices / Procedures (Select all that apply)
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Change in routine or work conditions
Established procedures not followed
Inadequate job planning or hazard assessment
Procedure unclear or unavailable
Task execution / work method used
Task performed outside normal scope of work
Time pressure or workload demands affecting task execution
Not applicable
Equipment, Tools, or Materials (Select all that apply)
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Defective or damaged equipment
Equipment malfunction or failure
Guarding or safety devices missing or inadequate
Improper tool or equipment selection
Required inspection or maintenance not performed
Not applicable
Human Factors (Select all that apply)
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Communication issues
Distraction or divided attention
Fatigue (extended hours or insufficient rest)
Ergonomic factors (posture, reach, force, strain)
Judgment / situational awareness
Inexperience with equipment or task
Physical overexertion (force/load events)
Stress or time-related pressure
Not applicable
Please explain why or how fatigue was a factor?
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0/0
Personal Protective Equipment (PPE)
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PPE not required for task
PPE required and worn correctly
PPE required but not used
Incorrect PPE used
PPE unavailable or not provided
Why was required PPE not used?
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0/0
Why was PPE unavailable or not provided?
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0/0
Supervision / Management Factors (Select all that apply)
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Inadequate enforcement of safety rules
Inadequate supervision at time of incident
Safety expectations not clearly communicated
Staffing levels or coverage issues
Not applicable
External / Other Factors (Select all that apply)
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Actions of third parties or the public
Contractor or vendor involvement
Emergency or unplanned response activity
Traffic or pedestrian interaction
Not applicable
Please explain, answer who, what, and why the factor was not reasonably foreseeable or controllable?
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0/0
Justification for "Not Applicable" Selection
You have selected “Not Applicable” for all contributing factor categories. Please explain how each category was evaluated and why none were determined to have contributed to this incident.
Describe the evaluation performed and the rationale for determining that no contributing factors applied.
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0/0
Property Damage Information
Property Type Damaged (Select all that apply)
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City vehicle
Heavy equipment / mobile equipment
Tools or small equipment
Building or facility
Infrastructure (signs, poles, guardrails, sidewalks)
IT or electronic equipment
Landscaping or grounds
Private or non-City property
Other
Briefly describe the property damaged and how the damage occurred.
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0/0
Did the injury/illness result in any of the following employee conditions? (select all that apply)
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Job restrictions/transfer (cannot perform regularly assigned tasks)
Lost work days (don't include the day of incident)
Occupational hearing loss
Loss of consciousness
Medical treatment beyond first aid
None of the above
Was the employee(s) involved? (select all that apply)
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Properly trained for the assigned job task
Adequately experienced for the assigned job task
Adequately supervised for the assigned job task
Involved in prior safety related incidents
List any APPLICABLE training and/or work experience
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List any previous safety related counseling
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Corrective action(s) taken to prevent or reduce future occurrence
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Corrective actions refer to process, environmental, training, or hazard control improvements intended to prevent recurrence, not disciplinary measures.
0/0
Corrective action(s) completed on or target date for completion
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-
Month
-
Day
Year
Date
Additional information/photos
Take Photo
Has a worker's compensation claim been started for this injury/illness? (Workers’ Compensation claims are initiated in accordance with City procedures and applicable state requirements.)
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Yes
No
Employee declined medical treatment and a Workers' Compensation claim was not initiated.
Risk Management Accident/Incident Report has been completed or will be completed for this incident.
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Yes
No
Was the city employee given a citation for the vehicle accident?
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Yes
No
Not Applicable
Was any of the vehicles involved in the vehicle accident towed away from the scene?
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Yes
No
Not Applicable
Was anyone involved in the accident taken to the hospital or other medical treatment facility for injuries related to the accident?
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Yes
No
Was the employee subject to post-accident alcohol and drug testing in accordance with City policy?
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Yes
No
Did the supervisor speak with the employee after the accident and observe no reasonable suspicion indicators of alcohol or drug impairment at that time? (Reasonable suspicion determinations are based on observable indicators and are governed by City policy and applicable regulations.)
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Yes
No
Not Applicable
By checking this box, I certify that the information I have entered is true and correct to the best of my knowledge and belief.
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Yes
Report submitted by (Supervisor level or above)
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First Name
Last Name
Submit
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