Incident Investigation Report Form.

Please note all RED highlighted fields must be completed prior to printing report

Date Injury Occurred:

Campus # & Location:

Date of This Report:

Time Injury Occurred:

Employee Information-Section 1

Employee Name: Employee ID#:

Employee Job Title: Date of Hire:

Employee Address:

Home Phone #: Date of Birth: Last 4 of Social Security #:

Work Phone #: Sex: Male Female

Employee Work Information-Section 2 # Of Hours Work Per Day: # Of Days Work Per Wk: Shift Start Time: Shift End Time:

Number of Total Weekly Hours: Check applicable box: Full-Time Part-Time

Supervisor:

Occupation at time of Incident:

Years of Experience in Occupation:

Supervisor at Time of Incident if Not Current Supervisor:

Incident Information-Section 3 Name of Person Reporting Incident:

Date of Investigation: Day of Injury:

Time Employee began

work on day of Injury:

Date of Last

Day Worked:

Date Returned

to Work: Number of days missed from work after Injury:

Injury Severity: (select one)

OSHA Recordability of Injury/Illness: (click all that apply) In-House First Aid Returned to work-Same Day

Sent to Doctor Unable to work next shift

Sutured/Stitched Unconscious

Hospitalized

Other: _____________________________________________

Work Restrictions:__________________________________

___________________________________________________

Recordable Non-Recordable

Fatality First Aid

First Aid (WC Claim) Property Damage

Medical Treatment (WC Claim) Significant Incident

Restricted Workday(s) Complaint

Time Loss

Other:

Injured Person Transported by – Click Box(es)

Ambulance Supervisor Self Other

Accompanied By: _________________________________________

Medical Treatment - Click Box(es) & Complete Blanks

Treatment Facility : ______________________________________

Doctor : __________________________________________________

Address: _______________________________________________________

Phone#: ________________________________________________________ Hospital : ________________________________________________

Address: _______________________________________________________

Phone #: ______________________________________________________

List All Witnesses to Incident:

Witness Name Phone # and Address

* Please Attach All Witness Statements to this Report

:

FROL#____________________

ampm

Supervisor Phone #:

1 Revised 04/2014. Copyright © 2008-2014 Corinthian Colleges, Inc. (CCi) Santa Ana, California, 92707. All rights reserved. The information contained

herein is proprietary and confidential. Any disclosure to unauthorized persons would be harmful to the Company's business and is expressly prohibited.

SAMPLE

Incident Investigation Report..

Investigation Information – Section 4

Exact Location of Incident:

Incident/Injury Reported To:

Sequence of Events: (Describe what happened before, during & after the incident)

(1) What specific job task was injured engaged in at the time of accident?

(2) The employee’s position relative to their immediate surroundings

(3) How was the employee doing what they were doing?

(4) What triggered the accident?

(5) Explain the type of accident that occurred and the cause

(6) Has the employee received any kind of treatment on this body part in the past? Yes No

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_________________________________________________________________________________________________________________

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_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

If yes on #(6) describe:

Nature of Injury – Click Box(es)

Allergies/Sensitivities

Foreign Body-Eye

Amputation

Foreign Body-Other than Eye

Asphyxiation

Fracture

Bite/Sting

Hearing Loss

Bruise/Contusion

Heart

Condition

Burn-Chemical

Hernia/Rupture

Burn-Contact

Infection

Burn-Electrical

Inflammation/Irritation

of Joints,Tendons or Muscles

Burn-Flame

Internal Bleeding

Carpal Tunnel Syndrome

Nervous System

Concussion

Pneumoconiosis

Concussion

w/Unconsciousness

Poisoning

Contagious

Conditions

Respiratory Conditions

Contusion

Scratch/Abrasion/Rash

Cut,Puncture,Open Wound

Sprains/Strains

Crush

Joints/Muscles/Tendons

Dislocation

____________________________

Stress, Mental

Disorders Associated

_________________________

w/Repeated Trauma

Multiple Injuries:

Electric Shock

OTHER:__________________

Excess Heat/Cold

_____________________________________

CLICK BOX(ES) of AFFECTED BODY PART(S)

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

_____________________________________

Exact Location of Incident

Multiple Head/Face Brain Head

ScalpEye(s)Mouth/NoseNeck

SkullFaceEar(s)Teeth

ShoulderShoulderUpper Back Upper BackUpper Arm Upper ArmChest Chest

ElbowElbowSides/Ribs Sides/RibsLower Back Lower BackAbdomen AbdomenForearm ForearmWrist WristHand HandFinger(s) Finger(s)Thigh ThighHip(s) Hip(s)Groin GroinKnee KneeLower Leg Lower LegAnkle AnkleFoot FootToe(s) Toe(s)

LEFT S I DE OF BODY

R IGHT S I DE OF BODY

On Date:

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

2 Revised 04/2014. Copyright © 2008-2014 Corinthian Colleges, Inc. (CCi) Santa Ana, California, 92707. All rights reserved. The information contained

herein is proprietary and confidential. Any disclosure to unauthorized persons would be harmful to the Company's business and is expressly prohibited.

SAMPLE

Incident Investigation Report..

Safety Coordinator's Investigation Information – Section 5

Job Task – Click all Box(es) that apply Unsafe Condition(s) – Click Box(es) Unsafe Act(s) – Click Box(es)

Ascending/Descending:

Clean Up:

Other:____________________

Forklift:

Material Handling:

Maintenance:

Maintenance Other:

Car/Truck:

Supervisory Task:

Tools:

Hand Powered

Walking:

Other:

Workspace Conditions:

Environment:

Inside/Outside Lighting Conditions:

Equipment:

Fire:

Guard/Barrier:

Housekeeping:

Protective Equipment:

Protruding Object(s):

Storage:

Substance:

Surface:

Tool(s):

Training:

Warning System:

Other:______________________________________

Other:__________________

Other:__________________

Office Tasks:

Stair(s) Ladder(s) Vehicle

Equipment

General Outside

Adjusting

Operating Clearing Clearing Jam

Repairing

Operating Repairing

Pushing Pulling Powered

Vehicle Electrical

Hydraulic Mechanical

Loading Unloading

Restocking Moving

Enter Work Through Area

Exit Work

Filing Typing(Repetitive)

Bending/Stooping

Sun Rain Snow

Severe

InadequateNone

Non-GivenInadequate

Defective Not-Available

SlippingHazard

TrippingHazard

Hazardous Non-Hazardous

Inadequate Improper

Good Fair Poor

SharpObject

SharpSurface

Improper Defective Inadequate

Fair Poor

Missing/Not Installed Inadequate

Explosion Hazard

Modified Exposed/Energized

Defective Failure

Good Fair Poor

Noise Gasses/Fumes/Etc

Cold Temp Hot Temp

Congested Restricted

Any & All Checked boxes above require further explanation below:

Any & All Checked boxes above require furtherexplanation below:

Any & All Checked boxes above require further explanation below:

Please Include Any Pictures/Video Pertaining To The Incident/Accident

Clothing/Footwear(Other than P.P.E.)

Cell Phone Use

Bypassed - Guard/Barrier

Bypassed - Safety Device

Disregard Instructions

Disregard Rules

Driving Actions

Drugs or Alcohol

Equipment Operator ActionsExcessive Speed

Failure - Lockout/Tagout

Failure - To Obtain Assistance

Failure - To Secure

Failure - To Use P.P.E.

Failure - To Warn

Horseplay/Distraction

Impairment - Physical

Improper Lifting

Improper Loading or Stacking

Improper Placement or Storage

Improper Pushing or Pulling

Inattention to Surroundings

Incorrect Method

Intentional Act/Sabotage

Lack of Knowledge

Lack of Training

Need for Assistance

Positioning for Task

Other: _______________________

Office Equipment:

Lifting

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Supplies:

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_____________________

______________________

_____________________________

Parking Lot Conditions:

Weather Conditions:

3 Revised 04/2014. Copyright © 2008-2014 Corinthian Colleges, Inc. (CCi) Santa Ana, California, 92707. All rights reserved. The information contained

herein is proprietary and confidential. Any disclosure to unauthorized persons would be harmful to the Company's business and is expressly prohibited.

SAMPLE

Incident Investigation Report..

Investigation Information – Section 6

Personal Protective Equipment Required for Job Task– Click Box(es)

Hard Hat Respiratory Protection Gloves

Safety Belt

Hearing Protection Goggles Apron

Seat Belt

Safety Glasses Face Shield Coveralls

Other:

PPE Availability – Click Box

Adequate Inadequate Improperly Used Not Available

Safety Rules – Click Box(es)

Adequate Inadequate None Not Enforced Other:______________________________

Training & Job Safety Analysis – Click Box(es)

Was there a safety orientation on this position? Yes No Is there a Job Safety Analysis on this job? Yes No

If yes, was the Job Safety Analysis adequate? Yes No If no, has one been ordered? Yes No If not adequate, has a revision been ordered? Yes No

Actions to Prevent Accident Recurrence - Click Box(es)

Action to improve design

Action to Improve Construction

Improved clean-up procedures

Improved lighting

Improved inspection procedures

Ordered Job Safety Analysis done

Ordered revision of Job Safety Analysis

Correction other than above:

_____________________________________________________________________________________________________________________________

Re- Instruct of employee(s) involved

Reprimand of employee(s) involved

Re- Instruct of others doing job

Temporary reassignment of Emp(s)

Permanent reassignment of Emp(s)

Correction of unnecessary congestion

Implement safety rule

Give new instructions

Inform all supervision

Improved noise/vibration control

Improved Personal Protective Equip.

Improved storage

Improved temperature control

Installation of guard or safety device

Tool/equipment repair/replacement

Use of safer materials/supplies

Corrective Actions / Fill in any Corrective Actions

Any Corrective Actions Person Responsible Completion Date

Required Signatures :

Employee Name:________________________________________ Signature:____________________________________________ Date:_____________

Supervisor Name:________________________________________ Signature:____________________________________________ Date:_____________

Safety Coord. Name:_____________________________________ Signature:____________________________________________ Date:_____________

_________________________________________________________________________________

Rolling Cart ___________________________

4 Revised 04/2014. Copyright © 2008-2014 Corinthian Colleges, Inc. (CCi) Santa Ana, California, 92707. All rights reserved. The information contained

herein is proprietary and confidential. Any disclosure to unauthorized persons would be harmful to the Company's business and is expressly prohibited.

SAMPLE