Centurion Power Incident Notification Form

Incident, Near Miss,Injury, Illness, Environmental Notification Form This reporting form must be completed as thoroughly as possible with as much information as is available at the time of the incident. Recognizing that some information will not be available immediately, document what you can and take pictures of the scene and damage. Notify the Supervisor and Safety Department of the incident immediately-
John Bland, Associate Director: 304.627.8891.

Instructions Nurse365 should be contacted for any injury that is not LIFE, LIMB, OR EYE SIGHT at Tel:+18552889490
(Company Name: Atwell, Location Code: 4020193-37)

A separate form must be filled out by each person involved in an incident as well as every witness to the incident. Preserve the scene until instructed otherwise by Robert Cole or the Site Project Manager of Safety. Answer all the questions to the best of your ability.
Your Name

First NameLast Name
Your Email Address
A copy of this report will be sent to you
Date of Incident/Near Miss

MonthDayYear
Date
Time of Incident/Near Miss

:HourMinutesAM/PM Option
Jobsite
Where did this incident happen?
Example: Substation A
Description of Incident/Near Miss Injury/Illness
Example: Laceration to left thumb.
What Happened
Provide as much detail as possible
Name of person providing information in "What Happened.”

First NameLast Name
Responding Safety Professional

First NameLast Name
Client Notification Time and Person Who Received Notification
Example: Dustin Smith 11:00AM
Was Law Enforcement or Emergency Responders Called
Name of Responding Agencies
Name/s of Responding Officer/s and or Emergency Responder/s
Number of People Involved
Company the involved person/s work for?
Type of Incident

Other
Persons Involved in the Incident
Phone Number/s of Person/s Involved
Supervisor of Person Involved

First NameLast Name
Supervisor Phone Number

Area CodePhone Number
Company(s) involved in incident
List all involved
Line of business
Electrical, concrete, civil
Upload Photos of incident

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Take photo with your phone and edit the photo to add a circle around the incident Cancelof
Upload Photos of incident

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Upload Photos of incident

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Take photo with your phone and edit the photo to add a circle around the incident Cancelof
Upload Photos of incident

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Take photo with your phone and edit the photo to add a circle around the incident Cancelof
Upload JHA for the day

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Upload any supporting documents

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Hot work permit, confined space permit etc. Cancelof
Upload additional photos

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Upload additional documents

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Immediate Site Actions Taken:
All work shut down, Safety Stand Down to discuss events.
Report Type
Root Cause Analysis and Lessons Learned

Please fill out all the information below before hitting submit.
Describe the problem and the source:
Provide the normal process:
Please explain the normal flow of the process on how to get the activity done without incident.
Why #1
Ask the why and answer the why all in the same box. (Example: Why did the forklift overturn? Because the D ring snapped.)
Why #2
Ask the why and answer the why all in the same box. (Example: Why did the D-Ring Snap? The D ring snapped because the welds were not completed.)
Why #3
Ask the why and answer the why all in the same box. (Example: Why weren’t the welds completed? The welds weren’t completed because the lifting device was in the shop for maintenance.)
Why #4
Ask the why and answer the why all in the same box. (Example: Why was the lifting device in the shop for maintenance? The lifting device was in the shop for maintenance because it was inspected and needed repairs and it should not have been in the field.)
Why #5 (Answer is the root cause)
Ask the why and answer the why all in the same box. (Example: Why was the lifting device in the field when it needed repairs and maintenance? The lifting device was in the field because the company does not have any policies and procedures to verify, inspect, and certify equipment after repairs are complete.)
Root Cause
Should be the answer from “Why 5” above.
Causal Factors:

Any unplanned, unintended contributor to an incident that if eliminated would have either prevented the occurrence of the incident or reduced its severity or frequency.
Direct Cause:
What directly caused the incident to occur? (Management did not use properly rated equipment for the task to be completed.)
List Contributing/Root Cause(s) or weak defenses:
List as many as possible (Example: Company does not have a written procedure to complete the task.)
List defenses that worked or lessons learned:
List as many as possible (Example: Use only rated lifting devices.)
Risk Factor(s)

Other
Explain your Risk Factor selection
Lessons Learned
Corrective/Preventative Actions
Should be Empty:

Root Cause Analysis and Lessons Learned

Causal Factors: