Safety Investigation Report
City of Newport News
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 employee began work
*
Hour Minutes
AM
PM
AM/PM Option
Time of incident
*
Hour Minutes
AM
PM
AM/PM Option
Employee
*
First Name
Last Name
Employee's age:
*
Employee Job Title
*
Employee Department
*
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
*
-
Month
-
Day
Year
Date
Employee Supervisor
*
First Name
Last Name
Supervisor Email
*
example@example.com
Forward Copy To Email (Department Safety Officer or Representative)
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
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."
*
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."
*
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."
*
Affected Body Part(s)
Head
Face
Eye
Ear
Neck
Shoulder
Chest
Abdomen
Back
Arm
Hand
Leg
Foot
Other
Injured Body Part-Please add as many rows needed to identify all body parts impacted
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
Not Applicable
Other
Description of property damage
*
What level of damage that resulted from the incident?
*
Please Select
None/NA
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)
Estimated cost to repair or replace property
Near Miss information
Description of near miss incident (how bad could it have been?)
Did the injury/illness result in any of the following employee conditions? (select all that apply)
*
Job restrictions/transfer (cannot perform regularly assigned tasks)
Lost work days (don't include the day of incident)
Hospitalization (admitted overnight)
Occupational hearing loss
Loss of consciousness
Medical treatment beyond first aid
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? (select 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
*
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
Not Applicable
Was the city employee given a citation for the vehicle accident?
Yes
No
Not Applicable
Was any of the vehicles involved in the vehicle accident towed away from the scene?
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?
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: