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Incident Investigation Report

This form is for supervisors and managers to report an incident that has occurred at a job-site. This includes incidents that have resulted in an injury or illness of an employee, contractor, or visitor.


 
Name of person involved in incident *
Name of person involved in incident
Individual's Status *
For employee information only
The following fields are required. Mark field as Not Applicable or N/A as appropriate.
Supervisor's Name *
Supervisor's Name
Incident Description
The following fields are required. Mark field as Not Applicable or N/A as appropriate.
Date of incident *
Date of incident
Injury or illness occurred as a result of incident *
When listing an employee, a phone number not required.
Medical Evaluation
Conducted By *
If company personnel, phone number not required.
Date of evaluation
Date of evaluation
If Injury or Illness occurred as a result of workplace incident
If answered yes, notify EH&S at 1.405.670.6800; 804 immediately after completing this report. Serious injuries and illnesses must be reported by EH&S to OSHA within 24 hours of incident. Incidents resulting in death must be reported by EH&S to OSHA within 8 hours after the person's death.
Is this a “sharps injury” (i.e. needlestick, cut, or abrasion) with an object that may have been contaminated with blood or other potentially infectious material *
Has the incident resulted in, or expected to result in, hospitalization for more than 24 hours *
Has the incident resulted in, or expected to result in, the person's death *
Posible Casual Factors
Process and/or environment-related *
Check all that possibly apply.
Personnel-related *
Check all that possibly apply.
Posible root cause(s) *
Factors contributing to the workplace condition(s) and/or act(s) identified above. Check all that possibly apply.
Mark field as Not Applicable or N/A as appropriate.
Planned Follow-up Efforts
Follow-up(s) *
Check all that possibly apply
Additional Incident Information
The following fields are required. Mark field as Not Applicable or N/A as appropriate.
Name of person completing report *
Name of person completing report
In submitting this incident investigation report you acknowledge the information above is accurate to the best of your knowledge. For questions on completing this report contact EH&S by phone 1.405.670.6800; 804 or via email safety@dowaero.com. You may be contacted for additional information and/or clarification.