Employee's Report Of Incident Form


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Description continued on attached sheets: ‰ Step 3: Why did the incident happen Unsafe workplace conditions: (Check all that apply) ‰ Inadequate guard ‰ Unguarded hazard ‰ Safety device is defective ‰ Tool or equipment defective ‰ Workstation layout is hazardous ‰ Unsafe lighting ‰ Unsafe ventilation ‰ Lack of needed personal protective equipment ‰ Lack of appropriate equipment / tools ‰ Unsafe clothing ‰ No training or insufficient training ‰ Other: Unsafe acts by people: (Check all that apply) ‰ Operating without permission ‰ Operating at unsafe speed ‰ Servicing equipment that has power to it ‰ Making a safety device inoperative ‰ Using defective equipment ‰ Using equipment in an unapproved way ‰ Unsafe lifting ‰ Taking an unsafe position or posture ‰ Distraction, teasing, horseplay ‰ Failure to wear personal protective equipment ‰ Failure to use the available equipment / tools ‰ Other: Why did the unsafe conditions exist Why did the unsafe acts occur Is there a reward (such as “the job can be done more quickly”, or “the product is less likely to be damaged”) that may have encouraged the unsafe conditions or acts ‰ Yes ‰ No If yes, describe: Were the unsafe acts or conditions reported prior to the incident ‰ Yes ‰ No Have there been similar incidents or near misses prior to this one ‰ Yes ‰ No 4 Step 4: How can future incidents be prevented What changes do you suggest to prevent this incident/near miss from happening again ‰ Stop this activity ‰ Guard the hazard ‰ Train the employee(s) ‰ Train the supervisor(s) ‰ Redesign task steps ‰ Redesign work station ‰ Write a new policy/rule ‰ Enforce existing policy ‰ Routinely inspect for the hazard ‰ Personal Protective Equipment ‰ Other: What should be (or has been) done to carry out the suggestion(s) checked above Description continued on attached sheets: ‰ Step 5: Who completed and reviewed this form (Please Print) Written by: Tit

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