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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