Appendix 2 - Forms. Appendix 2. Forms

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1 Appendix 2 - Forms Appendix 2 Forms 1. Job Site Inspection Checklist 2. Hayward Electric BBS Safety Observation Form 3. Confined Spaces 4. Respirator Log Sheet 5. Lockout Procedure 6. Daily Excavation Checklist 7. Hot Work Permit 8. Annual Ladder Safety Inspection Checklist 9. Lift Truck Inspection Form 10. Scaffolding Inspection Report 11. Pre-Lift Checklist 12. Job Safety Analysis 13. Job Hazard Analysis (JHA) 14. Supervisor s Report of Injury 15. Accident/Incident Investigation Report

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3 Job Site Inspection Checklist Job Name Inspected by Date 1. Job Information OSHA 300 forms posted and complete? OSHA poster posted? Phone no. for the nearest medical center posted? Weekly Safety Meetings up to date? Work areas properly signed and barricaded? Is each employee instructed in the recognition and avoidance of unsafe conditions? Are first aid supplies readily accessible? Is facility for the treatment of injured employees located within 15 minutes of the jobsite, if not, is there an employee trained in first aid at the site? Are telephone numbers, physicians, hospitals and ambulances conspicuously posted? Are potable drinking water and toilet facilities available at the site? Is there protection for bloodborne pathogens? 2. Housekeeping General neatness of work area? Projecting nails removed or bent over? Waste containers provided and used? Passageways and walkways clear? 3. Fire Prevention Adequate fire extinguishers, checked and accessible? Phone no. of fire department posted? No Smoking posted and enforced near flammables? 4. Electrical Extension cords or attachments cords with bare wires or missing ground prongs or damaged taken out of service? Ground fault circuit interrupters being used? Terminal boxes equipped with required covers? Are flexible cords and cables protected from damage? Are unused openings in cabinet boxes and fittings closed? Are all cabinets, panels and switches located in wet locations enclosed in weather proof enclosures? 5. Hand, Power & Powder Actuated Tools Hand tools inspected regularly? Broken handles and mushroom heads? Guards in place on machines, such as saws? Right tool being used for job at hand? Operators of powder actuated tools are licensed? 6. Fall Protection Safety rails and cables are secured properly? Employees exposed to fall hazards are tied off? Employees below protected from falling objects? Employees using body belts for positioning devices only? Y N N/A Comment Page 1 of 3

4 JOB SITE INSPECTION CHECKLIST Are employees working more than 6' above a lower level protected by guardrails, safety nets, personal fall arrest system? 7. Ladders Ladders extend at least 36" above the landing? Ladders are secured to prevent slipping, sliding, or falling? Ladders with split or missing rungs taken out of service? Stepladders used in fully open position? No step at top two rungs of stepladder? 8. Scaffolding All scaffolding inspected daily? Erected on sound rigid footing? Tied to structure as required? Guardrails, intermediate rails, toeboards and screens in place? Planking is sound and sturdy? Proper access provided? Employees below protected from falling objects? 9. Floor & Wall Openings All floor or deck openings are planked over or barricaded? Perimeter protection is in place? Deck planks are secured? Materials are stored away from edge? 10. Trenches, Excavation & Shoring Competent person on hand inspecting daily Excavations over 5' in depth are shored or sloped back? Materials are stored at least two feet from trench? Equipment is a safe distance from edge of trench or excavation? Ladders provided every 25' in trench more than 4' deep? Have underground utility installations been located? Are employees exposed to vehicular traffic wearing warning vests of reflectorized or highly visibility material? 11. Material Handling Materials are properly stored or stacked? Employees are using proper lifting methods? Tag lines are used to guide loads? Proper number of workers for each operation? 12. Welding & Burning Gas cylinders stored upright and secured? Proper separating distance between fuels and oxygen?(min 20') Burning/welding goggles or shields are used? Fire extinguishers are nearby? Hoses and regulators are in good condition? 13. Cranes Outriggers are extended and swing radius barricade in place? Operator is familiar with load carts? Crane operators logs are up-to-date? Employees kept from under suspended loads? Chains and sling inspected and tagged as required? Hand signal charts are on crane? Y N N/A Comment Page 2 of 3

5 JOB SITE INSPECTION CHECKLIST 14. Concrete Construction Employees are protected from cement dust? Exposed skin covered? Runways are adequate? Walls over 8' are supported? Are all protruding reinforcing rods covered? Is lockout/tagout procedure in use on any machinery where inadvertent operation could cause injury? Y N N/A Comment 15. Personal Protective Equipment Hard hats are being worn? Safety glasses are being worn? Respirators are used when required? Hearing protection being worn when required? Traffic vests being worn? 16. Vehicles Do vehicles, earth moving or compacting equipment with an obstructed view to the rear have a backup alarm or used with an observer? Do vehicles and earth moving equipment have seat belts and are they used? Are flagmen wearing reflectorized garments and using flags, sign paddles or lights? 17. Stairs Are flights of stairs with 4 or more risers equipped with standard stair railings or handrails? 18. Miscellaneous Is a written Hazard Communication Program on site including MSDS, materials list, container labeling, employee training. Is exposure to lead or lead based paint, such as paint removal controlled? Is exposure to silica, such as sandblasting, using sand or cutting brick or cinderblock controlled? Is exposure to asbestos controlled? 19. Unsafe Acts or Practices Observed (List): Signature Date Page 3 of 3

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7 Hayward Electric BBS Safety Observation Form Your concerns for safety and suggestions as how to improve our safety program are important to Hayward ELectric. Use this form to submit either safety improvement input and/or a BBS safety observation. Your name is optional and the name of the person being observed is not to be used.. This information will be used to continually improve our safety system and conditions. Improvement Input BBS Observation Unsafe Act Unsafe Condition Recognition Environmental Employee/Observer Input : Employee s Action Taken or Recommendation: Supervisor or Management Action Taken: Safety Observation S=Safe C=Concern Critical Factors PPE / Procedures / Methods Body Position / Mechanics Slips / Trips Equipment / Work Environment S C Eye & Head S C Proper Position S C Proper Footwear S C MSDS If Needed S C Hand & Body S C Ask for Help S C Aware of Hazards S C Lock Out S C Footwear S C Use Dolly S C Prompt Clean Up S C Tools are Safe S C Trained on Task S C Smaller Loads S C Tripping Hazards S C Adjacent Work S C Work Permit / JSA S C Don t Twist Body S C Not Rushing S C Signage if Needed S C All trained in BBS S C Get Close to Item S C Step Conditions S C Spill Control Observer s feedback given to other employee: Location: Observer Name: Date: Promptly after observation, give this form to your supervisor who will review it and who must then forward it to the Hayward Electric Safety Coordinator.

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9 CONFINED SPACES LOCATION OF CONFINED SPACE: YES NO QUESTIONS REGARDING CONFINED SPACE CONDITION 1. Are confined spaces thoroughly emptied of any corrosive or hazardous substances, such as acids or caustics, before entry? 2. Are all lines to a confined space, containing inert, toxic, flammable, or corrosive materials valved off and blanked or disconnected and separated before entry? 3. Are all impellers, agitators, or other moving parts and equipment inside confined spaces locked-out if they present a hazard? 4. Is either natural or mechanical ventilation provided prior to confined space entry? 5. Are appropriate atmospheric tests performed to check for oxygen deficiency, toxic substances and explosive concentrations in the confined space before entry? 6. Is adequate illumination provided for the work to be performed in the confined space? 7. Is the atmosphere inside the confined space frequently tested or continuously monitored during conduct of work? Is there an assigned safety standby employee outside of the confined space, when required, whose sole responsibility is to watch the work in process, sound an alarm if necessary, and render assistance? 8. Is the standby employee appropriately trained and equipped to handle and emergency? 9. Is the standby employee or other employees prohibited from entering the confined space without lifelines and respiratory equipment if there is any question as to the cause of an emergency? 10. Is approved respiratory equipment required if the atmosphere inside the confined space cannot be made acceptable? 11. Is all portable electrical equipment used inside confined spaces either grounded and insulated, or equipped with ground fault protection? 12. Before gas welding or burning is started in a confined space, are hoses checked for leaks, compressed gas bottles forbidden inside of the confined space, torches lighted only outside of the confined area and the confined area tested for an explosive atmosphere each time before a lighted torch is to be taken into the confined space? Page 1 of 2

10 YES NO QUESTIONS REGARDING CONFINED SPACE CONDITION (Continued) 13. If employees will be using oxygen-consuming equipment-such as salamanders, torches, and furnaces, in a confined space-is sufficient air provided to assure combustion without reducing the oxygen concentration of the atmosphere below 19.5 percent by volume? 14. Whenever combustion-type equipment is used in a confined space, are provisions made to ensure the exhaust gases are vented outside of the enclosure? 15. Is each confined space checked for decaying vegetation or animal matter which may produce methane? 16. Is the confined space checked for possible industrial waste which could contain toxic properties? 17. If the confined space is below the ground and near areas of motor vehicles will be operating, is it possible for vehicle exhaust or carbon monoxide to enter the space? OTHER COMMENTS REGARDING CONDITION OF CONFINED SPACE SIGNATURE OF PERSON COMPLETING FORM DATE PRINT NAME OF PERSON SIGNING Page 2 of 2

11 RESPIRATOR LOG SHEET Respirator Identification: DAILY INSPECTION DAILY WASH & CLEAN DATE FILTER REPLACED SANITIZE WEEKLY (Indicate date) INITIALS REMARKS &/OR COMMENTS NOTE: Please give this log sheet to Purchasing after it is completely filled.

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13 LOCKOUT/TAGOUT PROCEDURE FORM Building: Location/Room: Machine: Type of Energy Electrical Mechanical Pneumatic Hydraulic Potential Other Other Isolation Location(s) LOTO Device(s) Group LOTO? Yes No Yes No Yes No Yes No Yes No Yes No Yes No Shift Change? Yes No Yes No Yes No Yes No Yes No Yes No Yes No 1. Review copy of Energy Assessment Form. 2. Identify energy source(s) of this machine. 3. Identify switch, breaker, valve, disconnect, etc. to be locked out to isolate the energy source. Be as descriptive as possible. 4. Identify the exact type of lockout devices needed to ensure the isolation of energy for machine. 5. Is group lockout required? Yes No 6. Will there be shift changes during lockout procedures on this machine? Yes No Employee Signature: Area Supervisor Approval Signature: Safety Officer Approval Signature: Date: Date: Date: Page 1 of 2

14 LOCKOUT/TAGOUT PROCEDURE FORM These steps should be followed by the authorized employee(s) for lockout/tagout of machines during servicing or repair. Specific details for this machine should be listed in space provided. Step 1. Notify all affected employees that machine will be shut down to perform required work: Step 2. Authorized employee(s) shall identify the type and magnitude of the energy, the hazard of the energy to be controlled, and the method or means to control the energy: Step 3. The machine should be turned off or shut down using the procedure established for the machine or equipment. An orderly shutdown must be utilized to avoid any additional or increased hazard(s) to employees as a result of the equipment stoppage: Step 4. Energy isolating device(s) should be placed in such a manner as to isolate the machine or equipment from the energy source(s): Step 5. Install lockout/tagout device(s) on all energy isolating devices listed in Step 4: Step 6. Following the application of lockout or tagout devices to energy isolating devices, all potentially hazardous stored or residual energy shall be relieved, disconnected, restrained, and otherwise rendered safe: Step 7. Prior to starting work on machine, authorized employee(s) must verify the proper placement of the energy isolating device and the deenergization of the equipment. Authorized employee(s) must perform any equipment specific test to confirm that any hazardous energy has been released. After testing, all operating controls must be returned to the safe or off position: Machine is now ready for servicing or repair. After completion of work refer to Hayward Electric IIPP and customer s documents for procedures to re-energize machine. Page 2 of 2

15 DAILY EXCAVATION CHECKLIST Date & Time Client Inspected Project Name Approx. Temp. Job Number Approx. Wind Dir. Project Location Safety Rep Excavation Size (Length x Width x Soil Classification Depth) Protective System Used Activities In Excavation Competent Person Excavation > 4 feet If YES, complete a Confined Space Permit YES NO deep? BEFORE any person enters the excavation NOTE: Trenches over 4 feet in depth are considered excavations. Any item below marked NO must be corrected or controlled BEFORE any person enters the excavation. YES NO N/A POTENTIAL HAZARD GENERAL A. Employees protected from cave-ins & loose rock/soil that could roll into the excavation? B. Spoils, materials & equipment set back at least 4 feet from the edge of the excavation? C. Engineering designs for shoring &/or manufacturer's design specifications for trench box on site? D. Adequate signs posted and barricades provided? E. Training (toolbox meeting) conducted w/ employees prior to entering excavation? UTILITIES A. Utility company contacted & given 24 hours notice &/or utilities already located & marked? Dial 811 or (800) (California & Nevada) or (800) (Arizona) B. Overhead lines located, noted and reviewed with the operator? C. Utility locations reviewed with the operator & precautions taken to protect against contact? D. Utilities crossing the excavation supported, and protected from falling materials? E. Underground installations protected, supported or removed when excavation is open? KEEP ONE (1) COPY OF EACH DAILY EXCAVATION CHECKLIST ON SITE FOR THE PROJECT DURATION

16 Any item below marked NO must be corrected or controlled BEFORE any person enters the excavation. YES NO N/A POTENTIAL HAZARD (continued) WET CONDITIONS A. Precautions taken to protect employees from water accumulation (continuous dewatering)? B. Surface water or runoff diverted / controlled to prevent accumulation in the excavation? C. Inspection made after every rainstorm or other hazard increasing occurrence? HAZARDOUS ATMOSPHERES A. Air in the excavation tested for oxygen deficiency, combustibles, other contaminants? B. Atmospheric hazards present? C. Ventilation used in hazardous atmospheres? D. Emergency equipment available where hazardous atmospheres could or do exist? E. Safety harness and lifeline used? F. Supplied air necessary (if yes, contact safety department)? ENTRY & EXIT A. Exit (i.e. ladder, sloped wall) no further than 25 feet from ANY employee? B. Ladders secured and extend 3 feet above the edge of the trench? C. Wood ramps constructed of uniform material thickness and cleated together at the bottom? D. Employees protected from cave-ins when entering or exiting the excavation? OTHER COMMENTS REGARDING CONDITION OF EXCAVATION SIGNATURE OF COMPETENT PERSON WHO PERFORMED INSPECTION DATE PRINT NAME OF PERSON SIGNING KEEP ONE (1) COPY OF EACH DAILY EXCAVATION CHECKLIST ON SITE FOR THE PROJECT DURATION

17 BEFORE STARTING HOT WORK, REVIEW ALL SAFETY PRECAUTIONS. CAN THIS JOB BE AVOIDED OR IS THERE A SAFER WAY? THIS PERMIT IS REQUIRED FOR TEMPORARY OPERATIONS INVOLVING OPEN FLAME OR PRODUCING HEAT AND/OR SPARKS: WELDING, CUTTING, BRAZING, GRINDING, SOLDERING, OR USING A TORCH TO THAW PIPING OR HEAT MATERIAL. THE PERMIT APPLIES ONLY TO THIS JOB, IN THE AREA SPECIFIED, DURING THE TIME AND DATE NOTED. INSTRUCTIONS PRECAUTION & SAFEGUARD CHECKLIST SUPERVISOR: Fire extinguisher available. 1. Complete PRECAUTION & SAFEGUARD Hot work equipment in good repair. CHECKLIST at right. Hazardous energy locked out. 2. Complete this permit form and issue to person performing hot work procedure. REQUIREMENTS WITHIN 35 FT OF WORK: 3. Verify FIRE WATCH. Flammable liquids and combustible material removed from area. HOT WORK PERFORMED BY: Company Employee Contractor: WORK ORDER NO.: LOCATION/BLDG/ROOM/FLOOR: Floors swept and overhead structure cleaned of dust, lint and debris. Fire-resistive covers and metal shields provided as needed. All floor and wall openings covered and or protected. WALLS/CEILINGS: remove combustibles away from opposite side or adjacent structures. WORK TO BE PERFORMED: PERSON PERFORMING WORK/DEPT.: WORK ON ENCLOSED/CONFINED EQUIP: Adequate ventilation is provided. Atmosphere checked with gas detector. Purge any flammable vapors. Confined Space Permit obtained, if required. FIRE WATCH: SUPERVISOR SIGNATURE: (obtain prior to job) I have verified that the above location has been inspected and The required PRECAUTIONS & SAFEGUARDS have been taken. Permission is authorized only for the work described above. Trained and equipped Fire Watch provided during operations and at least 30 minutes after. SPECIAL INSTRUCTIONS: PERMIT DATE: TIME: EXPIRES FINAL CHECK DATE: TIME: WORK DATE: TIME: COMPLETE EMPLOYEE SIGNATURE: SUPERVISOR SIGNATURE:

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19 ANNUAL LADDER SAFETY INSPECTION CHECKLIST Name of Inspector: Site Location: Date: Time: Instructions: 1) Inspect all step / extension ladders and stools using checklist below. 2) Affix inspection tag with date on all ladders passing inspection 3) Tag defective ladders Out of Service and discard if beyond repair 4) Note deficiencies/corrective actions in Comment section below. 5) Keep a copy of inspection sheet in site in Hayward Electric Files NOTE ONLY NON-CONDUCTIVE (Fiberglass or Wood) Ladders are allowed on Job Sites Y N 1. Broken, bent or missing steps, rungs, cleats, or rails? 2. Steps and rungs free of water, grease, oil or other slippery substance? 3. Free of splits, cracks, rust corrosion and dry rot? 4. Free of sharp edges, cuts, burrs, etc.? 5. Fallen or misused ladders for excessive dents or other damage? 6. Loose or bent hinges that can t be fully opened or locked in place? 7. Stable and completely balanced (not shaking or swaying) with all legs resting firmly on the floor? 8. Loose, broken or missing extension locks to ensure safe overlap of extension ladder sections? 9. Damaged or worn non-slip bases, safety feet, wheels or casters? 10. Cross-over ladders have railings and non-slip steps? 11. Damaged or corroded parts of metal cage (fixed vertical ladders > 20 ft only)? 12. Weight capacity label attached? 13. Other structural defects or operating problems? Ladder No. Department Comments: (Note deficiencies and corrective actions) Deficiency Corrective Actions (Tag, repair, discard)

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21 Name of Operator: Make/Model: Hours Meter Reading: Lift Truck Inspection Form Date: Shift: Supervisor s Name: Perform at the start of every shift. Report all unsafe conditions to your supervisor immediately. Do not use unsafe unit, pull the key and tag the unit unsafe for use. Condition Checks Tires, Wheels (Wear or Damage) Horn, Gauges, Lights and Alarms Fire Extinguisher Capacity Plate (Legible and Correct) Lift and Tilt Cylinders (Modified or Damaged) Overhead Guard (Modified or Damaged) Engine Oil Level Engine Coolant Level * (Recovery Bottle) Radiator (Leaks or Plugged with Dirt) Battery (Water Level, Secured & Charged) Transmission Fluid Level Hydraulic Fluid Level Fuel System (Leaks & Tank Level) Operation Checks Forward and Reverse (trans / controller) Service Brakes (Pedal Fade and Pulling) Emergency Brake (Correct Adjustment) Steering (Smooth Operation and Play) Limit Switches Functioning Hoist, Tilt and Attachments Boom Controls (ground and basket) Seat Belt Ropes (All ropes and slings in good shape) Hood and Seat Latches Good Good Needs Attention Needs Attention Unsafe Unsafe Explain all unsafe conditions/comments: Do not operate this unit until all discrepancies have been corrected. * NEVER open a hot or warm radiator cap. I have Inspected the above piece of equipment and find it safe to operate: Operator s Signature:

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23 SCAFFOLDING INSPECTION REPORT CLIENT: JOB NO: DATE: SCAFFOLD LOCATION: SCAFFOLD SIZE: TIME: : AM / PM INSPECTED BY: SECTION 1. NOTE: Scaffold shall not be used unless these items are found satisfactory. YES NO COMMENTS 1. Base plates/screw jacks on firm contact with sills/deck to prevent settling. 2. Scaffold appears to be level and verticals are plumb. 3. Safe, proper access and egress provided to all work platforms. 4. All platforms properly/tightly planked and secured from movement. 5. All toeboards secured in place. 6. All guardrails and midrails in place. 7. Are vertical legs rigidly braced to prevent swaying. 8. Scaffold anchored or equalized (4 to 1) to prevent movement (butts/ties installed). 9. No energized, unprotected electrical is within 12 feet of the scaffold. 10. Has the scaffold been tagged and has not been altered. Page 1 of 2

24 SECTION 2. NOTE: Scaffold shall not be used unless these items are found satisfactory. YES NO COMMENTS 11. Scaffold planks construction grade lumber and in sound condition. 12. Are all planking and toeboards in place and secured. 13. All guardrails and midrails in place and secured. 14. All tools and material raised and lowered to locations just carried by employees. 15. Working platforms clear of all loose tools, cords, material, etc. 16. Exit ways and ladders clear and unobstructed. 17. Stair and planks free of debris or slippery surface. 18. Work being performed on the scaffold accordance with load ratings. 19. Have barricades been installed, scaffold tags been placed properly. Notes: SIGNATURE OF COMPETENT PERSON WHO PERFORMED INSPECTION DATE PRINT NAME OF PERSON SIGNING Page 2 of 2

25 Pre-Lift Checklist Location of Lift: TASKS YES NO 1. Crane operator meets company qualification requirements? 2. Lift calculations and rigging plan completed? 3. Are lift equipment swing & travel requirements & clearances known? 4. Are all required approvals/permits signed? 5. Crane inspections up to date (Annual/Monthly/Daily)? 6. Weather conditions and wind speed acceptable? 7. Has the stability of the ground been assured by soil bearing analysis? 8. Location and size of underground facilities are known? 9. Matting and/or outrigger pads inspected and approved? 10. Electrical equipment and power lines at required distance? 11. Rigging Inspected for defects? 12. Engineered lifting lugs fabricated and installed correctly? 13. Connecting/disconnecting means been developed? 14. Have the safety precautions been reviewed? 15. Is survey equipment required? 16. The total lifted weight is below 95% of capacity? 17. Signal person(s) assigned? 18. Safe Plan of Action (SPA) Completed? 19. Pre-Lift Meeting/Task Safety Awareness Meeting (TSA) held? 20. Hoist area & load path cleared of non-essential personnel? 21. Crane set up per the lift plan (radius, configuration, etc)? 22. Rigging equipment and tag line(s) installed per plan? SIGNATURE OF PERSON COMPLETING FORM DATE PRINT NAME OF PERSON SIGNING

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27 Job Safety Analysis Field Team: Date Job Description: Job Site: New Company Names: Revised Sequence of Key Job Steps Potential Hazard(s) Recommended Action What conditions, job changes or distraction will trigger the use of Stop Work Authority on the Job Participants (signatures required by all affected personnel In case of an incident, the following people will be contacted: CPL Rep: Ph # Contr. Rep: Ph # Other: Ph # Hazard Identification Tools Gravity: Falling objects Roofs to collapse, People to trip & fall Motion: Movement of vehicles, vessels, water, wind or body movements Mechanical: Rotating equipment Drive belts, conveyors Motors or compressed springs Electrical: Power Lines, transformers Static charges, lightening Wiring and batteries Pressure: In piping, compress cylinders Pneumatic and hydraulic equip. Temperature: Including ignition sources Hot or cold surfaces, steam Friction and weather Chemical: Like vapors, combustibles Corrosives, welding fumesmical Biological: Bacteria, viruses, animals, insects, contaminated food/waterical Radiation: Solar rays, microwaves, x-rays, welding arcs Sound: Equipment noise, vibration, high-pressure release, voice communication

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29 JOB HAZARD ANALYSIS (JHA) LOCATION: DATE: JOB #: ANALYSIS DONE BY: ANALYZER S SIGNATURE: Complete this form by: 1) Identify the Task you are going to perform in the TASK column. 2) List the Potential Hazards for the task in the POTENTIAL HAZARDS column. 3) List the Safe Job Procedure and PPE to eliminate the Hazard in the SAFE WORK PROCEDURES column. 4) Identify who will mitigate the Potential Hazards in the ACTION BY column. 5) Identify the Completion Date of the mitigation in the COMPLETION DATE column. TASK POTENTIAL HAZARDS SAFE WORK PRACTICES ACTION BY COMPLETION DATE

30 HAYWARD ELECTRIC ENERGIZED WORK JOB HAZARD ANALYSIS (JHA) The undersigned have read, or have had read to them, and understand the general and special precautions to be observed and the protective equipment requirements of Hayward Electric s specific procedures for working on energized equipment and/or permit(s) issued to them on numbered covering work at the scope of which is: Additionally, all of the undersigned have discussed the specific job they are to perform with the emphasis on the hazards attendant to its performance, the means of abating or controlling the hazards identified, possible conflicts with other jobs in the immediate area which could result in putting them at risk and a general awareness of conditions in the area in which they are working. THE DISCUSSION HAS BE ON THE REVERSE SIDE HEREOF, REDUCED TO ENERGIZED WORK JOB HAZARD ANALYSIS. Crew Members: FOREMAN DATE

31 Supervisor s Report of Injury Name of Injured Person Date of Birth Telephone Number Address City State Zip (Circle one) Male Female What part of the body was injured? Describe in detail. What was the nature of the injury? Describe in detail. Describe fully how the accident happened? What was employee doing prior to the event? What equipment, tools being using? Names of all witnesses: Date of Event Time of Event Exact location of event: What caused the event? Were safety regulations in place and used? If not, what was wrong? Employee went to doctor/hospital? Doctor s Name Hospital Name Recommended preventive action to take in the future to prevent reoccurrence. Supervisor Signature Date

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33 Accident/Incident Investigation Report Instructions: Complete this form as soon as possible after an incident that results in serious injury or illness. (Optional: Use to investigate a minor injury or near miss that could have resulted in a serious injury or illness.) This is a report of a: Death Lost Time Dr. Visit Only First Aid Only Near Miss Date of incident: This report is made by: Employee Supervisor Team Other Step 1: Injured employee (complete this part for each injured employee) Name: Sex: Male Female Age: Department: Part of body affected: (shade all that apply) Job title at time of incident: Nature of injury: (most serious one) Abrasion, scrapes Amputation Broken bone Bruise Burn (heat) Burn (chemical) Concussion (to the head) Crushing Injury Cut, laceration, puncture Hernia Illness Sprain, strain Damage to a body system: Other This employee works: Regular full time Regular part time Seasonal Temporary Months with this HE Months doing this job: Step 2: Describe the incident Exact location of the incident: Exact time: What part of employee s workday? Entering or leaving work Doing normal work activities During meal period During break Working overtime Other Names of witnesses (if any): Page 1 of 3

34 Number of attachments: Written witness statements: Photographs: Maps / drawings: What personal protective equipment was being used (if any)? Describe, step-by-step the events that led up to the injury. Include names of any machines, parts, objects, tools, materials and other important details. 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? Have there been similar incidents or near misses prior to this one? Yes No Yes No Page 2 of 3

35 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: Title: Department: Names of investigation team members: Date: Reviewed by: Title: Date: Page 3 of 3

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