Incident Investigation
Type of Incident:
*
Injury
Property Damage
Auto Accident
Dropped Object
Employment/Harassment
Other
Name of Involved Employee:
*
First Name
Last Name
Employee's Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Employee Hire Date:
*
-
Month
-
Day
Year
Date
Employee Age:
Employee Time in Craft:
Employee Trade:
*
Employee Union Rank:
*
Superintendent:
*
First Name
Last Name
Superintendent Email
*
example@example.com
Employee Supervisor / Foreman:
*
First Name
Last Name
Department:
*
Please Select
APICC National Services
APICC - Minnesota
APICC - North Dakota
APICC - Upper Michigan
APICC - Lower Michigan
API Garage Door
M Lukas
Milwaukee Scaffold
National Scaffold
Nyco
Portland Scaffold
Scaffold Service
Project Name:
*
Project Number:
*
Location of Incident:
*
Incident Date and Time:
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Date Reported to API:
*
-
Month
-
Day
Year
Date
Incident Description:
*
Body Part Effected (Check All That Apply)
Head
Face
Neck
Shoulder
Arm
Elbow
Wrist
Hand
Finger(s)
Chest
Stomach Area
Hips
Leg
Knee
Ankle
Foot
Toes
Specific Body Part Effected:
Left, Right, Upper, Lower, Mid
Weather Conditions (Check All That Apply)
*
Weather was not a factor.
Sunny / Clear
Hot
Humid
High Winds
Cloudy
Rain / Thunderstorm
Snow
Sleet / Ice
Walking / Working Surface Condition (Check All That Apply)
*
Flat / Even
Dry
Wet
Mud
Snow / Ice
Slippery
Rocky
Uneven
Debris / Materials / Trash
Key Contributing Factors (Check All That Apply)
*
Rushing
Fatigue
Frustration
Low Light
Overexertion
Distraction
Lack of Training
Not following rules
Repeated Task
Experience Level
No training
Poor directions
High traffic
Housekeeping
Was the employee drug tested?
*
Yes
No
Was the employee tested for alcohol?
*
Yes
No
Were workers from other companies involved?
*
Yes
No
If yes, what company?
Number of Witnesses:
*
Was the employee authorized to work in the area which the incident occurred?
*
Yes
No
Did the employee fill out a PTA / STARRT / JSA / or any other documentation related to this work location or process?
*
Yes
No
Did the PTA / STARRT / JSA description match the work being performed?
*
Yes
No
Was the hazard or condition identified on the PTA / STARRT / JSA?
*
Yes
No
Did the employee undergo any incident related job, hazard, or location specific training prior to this incident?
Yes
No
If Yes, what training occurred?
Did any involved employees engage in any unsafe acts?
*
Yes
No
If Yes, what unsafe act occurred?
What corrective action was implemented to prevent a similar incident from occurring?
*
Check any additional factors that should be considered in this investigation:
Barricade rope was not used correctly.
Tools were not tethered.
Walking / working surface was slippery.
Employee was not trained.
Employee was wearing wrong PPE.
Poor housekeeping.
Report Completed By:
*
First Name
Last Name
Title:
*
Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Report:
*
-
Month
-
Day
Year
Date
If you would like to receive a copy of this report, enter your email address.
example@example.com
Attach Employee Written Incident Report
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Attach PTA/JSA/STARRT Document
*
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Attach Insurance Card (Auto Accident)
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