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    IIPP Campus Near Miss and Accident Report

    Uploaded by

    Abdul Aziz Mohammed
    This document provides a template for reporting near-miss and accident investigations. The template collects details about the incident, injured employee, contributing factors, and aims to identify root causes to prevent future incidents without blame.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    IIPP Campus Near Miss and Accident Report

    Uploaded by

    Abdul Aziz Mohammed
    28 views4 pages
    This document provides a template for reporting near-miss and accident investigations. The template collects details about the incident, injured employee, contributing factors, and aims to identify root causes to prevent future incidents without blame.

    Original Title

    IIPP-Campus-Near-Miss-and-Accident-Report

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    This document provides a template for reporting near-miss and accident investigations. The template collects details about the incident, injured employee, contributing factors, and aims to identify root causes to prevent future incidents without blame.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    28 views4 pages

    IIPP Campus Near Miss and Accident Report

    Uploaded by

    Abdul Aziz Mohammed
    This document provides a template for reporting near-miss and accident investigations. The template collects details about the incident, injured employee, contributing factors, and aims to identify root causes to prevent future incidents without blame.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    You are on page 1of 4

    Appendix G

    NEAR-MISS AND ACCIDENT


    INVESTIGATION REPORT

    This form is designed to give as complete a picture as possible of the circumstances of the incident
    and to ensure details have been recorded in an orderly fashion. The purpose of this investigation
    is to find the root causes of the incident and to NOT assign blame or fault to any individual.

    Supervisor of Employee Involved:_________________________________________________


    School/Department:____________________________________ Date Reported:___________

    1.Name of Employee Involved:_________________________________________________


    2.Employee’s Job Title:_________________________ 3.Date of Incident:_____________

    4. What type of incident occurred


    Near-Miss Accident w/ injury Accident multiple inj. Other

    5.How long has the person been employed


    Less than 1 mo. 1-5 mos. 6 mos.-5 yrs. more than 5 yrs.

    6.Employment category
    Regular, full-time Regular, part-time Temporary Student
    Non-Employee

    7. Time of Incident
    A. _____a.m. _____p.m. B. Time within shift _________ C. Type of shift_________

    8. Phase of employee’s workday at time of injury


    During rest period During meal period Working overtime
    Entering or leaving work Performing work duties Other
    Appendix G

    NEAR-MISS AND ACCIDENT


    INVESTIGATION REPORT

    This form is designed to give as complete a picture as possible of the circumstances of the incident
    and to ensure details have been recorded in an orderly fashion. The purpose of this investigation
    is to find the root causes of the incident and to NOT assign blame or fault to any individual.

    9. Describe the incident:


    Describe the overall nature of the incident.

    Description of Event: What was employee doing just before and at the time of the incident?

    What work conditions contributed to the incident?


    Give details of any conditions that may be relevant, e.g., lighting, floors, steps, ramps, oil, moisture etc.

    Was PPE used? If not why?

    10. Nature and Extent of Potential/Real Injury:

    11. Nature and Extent of Potential/Real Property Damage:


    Appendix G

    NEAR-MISS AND ACCIDENT


    INVESTIGATION REPORT

    This form is designed to give as complete a picture as possible of the circumstances of the incident
    and to ensure details have been recorded in an orderly fashion. The purpose of this investigation
    is to find the root causes of the incident and to NOT assign blame or fault to any individual.

    12. Task and Activity at Time of Near-Miss


    General type of task:__________________________________________________________
    Specific activity:______________________________________________________________
    Employee was working:
    Alone With crew or fellow worker Other: specify________________

    13. Posture of employee

    14. Supervision at time of accident


    Directly supervised Indirectly supervised Supervision not feasible Not supervised

    15. Factors that contributed to near-miss – Please check all that apply

    Hazard Training & Certification Other


    Not recognized/identified Insufficient training Weather/temperature
    Identified, but not addressed Circumstances not covered Extended work hours
    Inadequate repair Ineffective training Worker fatigue
    Worker not authorized Physical overexertion
    Work Procedures Outdated Training Work in elevated area
    None developed Chemical Use
    Not followed Communication Biological agent
    Partially followed Breakdown in verbal communication Radiation
    Not understood Breakdown in written communication Electricity
    Not appropriate Confusion after communication Mechanical
    Not communicated Other____________________ Animals
    Other
    Appendix G

    NEAR-MISS AND ACCIDENT


    INVESTIGATION REPORT

    Facilities/Equipment PPE Requirements


    Personal protective equipment (see below)
    Req. Used Type
    Faulty equipment
    Eye ________________
    Poor/inadequate maintenance
    Face ________________
    Inappropriate use
    Hearing ________________
    Missing guards
    Skin/Glove ________________
    Obsolete/antiquated
    Foot ________________
    Inadequate design
    Other ________________
    Ergonomic factors
    Equipment failure
    Trip hazard
    Slip hazard
    Struck by Other

    Additional Questions:
    Where there any witness to the event? If so who and can they be contacted?

    Where there established procedure for the work being done? YES NO

    If Yes were they being complied with, How? If not complied with, Why?

    Was there any medical/first aid given at the scene? If so what and by who?

    Are you able to determine any root causes of why this incident occurred?
    Or are there any additional comments?

    Please attach any photos, drawings, measurements or statements to this report.

    Name of person completing this form: (Please Print, Sign and Date)

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