Safety and Environmental Incident Report Form

This form is for the following types of incidents: near misses, injuries, vehicle incidents, property damage, unsafe conditions/acts, and environmental spills/release.

Date of Report*

Date of Incident*

Time AM/PM*

Name

Job Title

Territory or Dept*

Select or enter value

Your Supervisor*

Location of Incident-please include street address*

Ryko Incident Type

Select or enter value

File Attachments

Please upload interview notes, pictures of the incident location, or scanned items.

Drag and drop files here or

Describe the activity prior to incident*

Be specific. Describe tools, materials, tasks, weather conditions.

How did the incident occur?*

Describe the injury, illness, damage or release:*

STOP HERE IF YOU HAD A NEAR MISS;OTHERWISE PLEASE CONTINUE

Did you report this incident to your supervisor?

Select or enter value

Was medical care administered? By who?

Did you see a doctor? Where?

What object or substance harmed the employee?

Were there any witnesses?

Was the work area a factor? Explain.

Did the area provide sufficient work space, tools, controls, and materials within reach?

Were machine guards/safeguards factor? Explain.

All barriers, guards, devices, and measures in place to control exposure to a hazard(s)?

Was protective equipment a factor? Explain.

Was proper enviromental/safety equipment provided for ventialtion, elevated work, and chemical handling?

Was PPE a factor? Explain.

Were appropriate gloves, footwear, eye/face/body protection, respirators, hearing protection, arc flash gear worn?

Was machinery/equipment a factor? Explain.

Was machinery/equipment required for the job available and utilized?

Were work methods or procedures a factor? Explain.

Did employee use work practices/methods as prescribed?

Was lighting, ventilation, heat or cold a factor?

Was lighting and ventilation adequate for the environment and the number of persons performing the task?

Was workload/pace a factor? Explain.

Was work performed at a safe pace? Was there adequate manpower for the task?

Was training or experience a factor? Explain.

Was training adequate? Was experience adequate?

Was supervision a factor? Explain.

Did supervision verify training and job tasks by observing work habits to ensure practices were being followed?

Was enforcement of work rules a factor? Explain.

Were work rules established and known by employees?

Was supervisory foresight a factor? Explain.

Supervisors should anticipate hazards.

Based on the data, what was the root cause(s)?

Ask why each condition contributed to the incident. Formulate a corrective action for each root cause found.

Engineered Corrective Actions:

Engineering is the highest quality corrective action.

Administrative Corrective Actions:

Administrative and work practices are preferable to PPE corrective actions.

Work Practices Corrective Actions:

Work practices are preferable to PPE corrective actions.

PPE Corrective Actions:

Should be the least desireable corrective action.

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