Safety Investigation
What type of incident are you reporting?
*
Injury/Illness only
Vehicle/Property damage only
Vehicle/Property damage and Injury
Near miss
Date of incident
*
-
Month
-
Day
Year
Date
Time of incident
*
Hour Minutes
AM
PM
AM/PM Option
Employee
*
First Name
Last Name
Employee Job Title
*
Employee Department
*
Employee Supervisor
*
First Name
Last Name
Supervisor Email
*
example@example.com
Forward Copy To Email
example@example.com
Was there a witness?
*
Yes
No
Witness
First Name
Last Name
Witness Contact Info
Phone #
Email
Did this incident happen in a Traffic Control Work Zone?
*
Yes
No
Incident location
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Injury Information
Affected Body Part(s)
Head
Face
Eye
Ear
Neck
Shoulder
Chest
Abdomen
Back
Arm
Hand
Leg
Foot
Other
Injury/Illness caused by
Struck by object
Struck by person
Striking against or stepping on (body)
Collision (vehicles)
Strains (lifting, pulling, pushing, twisting)
Cut, puncture, scrape
Slips, Trips, Falls
Heat or cold exposure
Inhalation or ingestion
Airborne exposure
Surface exposure (skin contact)
Electrical
Animal or insect bite
Other
Description of other
Property Damage Information
Property type
Vehicle
Structure
Equipment/Tools
Furniture
Bldg Fixtures
Electronics
Personal Property
Other
Description of property damage
Estimated cost to repair or replace property
Near Miss information
Description of near miss incident (how bad could it have been?)
Specific job task at time of incident
*
Describe how the accident/incident happened
*
What level of severity resulted from the incident?
*
Low (little or no property damage, no medical treatment beyond first-aid)
Moderate (significant property damage or injury resulting in light duty/lost work)
High (serious damage, multiple injuries or employee hospitalized)
Very High (catastrophic damage, mass casualties, fatality, amputation)
Did the injury/illness result in any of the following?
*
Job restrictions/transfer (cannot perform regularly assigned tasks)
Lost work days (don't include the day of incident)
Hospitalization (admitted overnight)
None of the above
Contributing Factors (select all that apply)
*
Human error
Fatigue
Overexertion
Lack of training
Lack of supervision
Lack of procedure
Improper procedure
Disregard of safeguards
Lack of safeguards
Distraction
Material failure
Equipment failure
Miscommunication
Unsafe Design
Lack of PPE
Environmental Conditions
Poor work site housekeeping/cleanliness
Negligence
Other
Was the employee(s) involved? (check all that apply)
*
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
*
List any previous safety related counseling
*
How often is this most likely to happen again?
*
Almost Never
Rarely (once or twice a year)
Occasionally (more than twice a year)
Frequently (once a month or more)
Corrective action(s) taken to prevent or reduce future occurrence
*
Corrective action(s) completed on or target date for completion
*
-
Month
-
Day
Year
Date
Additional information/photos
Take Photo
Report submitted by (Supervisor level or above)
*
First Name
Last Name
Has a worker's compensation claim been started for this injury/illness?
Yes
No
Has a Vehicle Accident Report been submitted to Risk Management?
Yes
No
Was the city employee given a citation for the vehicle accident?
Yes
No
Was any of the vehicles involved in the vehicle accident towed away from the scene?
Yes
No
Was anyone involved in the accident taken to the hospital or other medical treatment facility for injuries related to the accident?
Yes
No
Was the employee taken for a post-accident alcohol and drug testing in accordance with city policy?
Yes
No
Did a supervisor speak with the employee after the accident and determine there was no reasonable suspicion of impairment from alcohol or drugs involved?
Yes
No
By checking this box, I certify that the information I have entered is true and correct to the best of my knowledge and belief.
*
Yes
Submit
Clear All Questions
Should be Empty: