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Accident/Injury Report: TO BE COMPLETED Within 24 Hours

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50 views2 pages

Accident/Injury Report: TO BE COMPLETED Within 24 Hours

Uploaded by

dearsirbhartey
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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ACCIDENT/INJURY REPORT

TO BE COMPLETED within 24 hours

This form is to be used to report workplace accidents to include: near misses, injuries, illnesses, or exposures. The
person reporting will complete Part I of this report. The supervisor or instructor will conduct a thorough review and
complete Part II. The Safety Officer will investigate the event, identify a primary cause, if possible, add any written
recommendations and distribute the form when completed.

Do not move equipment involved in a work-related accident involving a death, inpatient hospitalization, amputation, or loss
of an eye. The equipment must not be moved until a representative of the Department of Labor and Industries
investigates the accident and releases the equipment unless moving the equipment is necessary to: a) Remove any
victims or b) Prevent further incidents and injuries.
PART 1 – COMPLETE WITHIN 24 HOURS
1. Employee Contract staff Volunteer
2. Name (Last, First, MI) 3. Sex 4. Birthdate 5. Work phone Ext.
M F X
6. Job classification/Working title 7. Normal scheduled shift 8. Days off
Day Afternoon Night
9. Assigned work location 10. Address/Mail stop

11a. Facility name 11b. Building 11c. General

12. Incident date 13. Incident time


AM PM
14. What part(s) of body was affected (e.g., right ankle, left index finger, lungs)?

15. Type of injury (Check all that apply)


No injury/illness Dizziness Blood/Bodily fluids
Ache/Soreness Disease/Infection Fumes/Gas/Vapors
Noise Tingling/Numbness Wound/Abrasion
Burn-Chemical Contusion/Bruise(s) Nausea
Burn-Flame Contact with Sprain/Strain
Burn-Steam toxics/chemicals Other
Needle stick
16. How did you sustain this injury?

Front Back
17. What have you done or are going to do to ensure accidents/incidents of this type do not happen in the future?

18. Did this incident occur during training? 19. Do you believe you were assaulted by an individual under
Yes No the Department’s jurisdiction?
(Per DOC 830.180 Assault Benefits for Employees)
Yes No
20. Was this a work related injury? 21. Was this an aggravation of a previous injury?
Yes No Yes No
22. To whom did you report this to? 23. Name of witness, their title, and work telephone number(s)

Supervisor/Instructor name (Last, First, MI)

Signature Date

DOC 03-133 (Rev. 11/08/21) Page 1 of 2 DOC 420.205, DOC 420.385, DOC 600.025,
DOC 830.180, DOC 830.200, DOC 890.000, DOC 890.095, DOC 890.600
PART II – TO BE COMPLETED BY THE SUPERVISOR
(OR INSTRUCTOR IF INJURED DURING TRAINING) WITHIN 7 DAYS
Investigation to be completed and sent to the Safety Officer within 7 days. Please use the following guide to assist in
completing this section and the review process. Verify the person’s description of the accident/injury in Part I of the form. If
necessary, diagram the accident/injury scene and/or take pictures, which can be attached to this section.
Determine:
➢ If there were any witnesses, obtain witness statements
➢ If other corrective action has taken place or is required
➢ If training is an issue and, if so, if it has been scheduled or coordinated
24. Based on your Fact Find Review, how did the person sustain a work-related injury? Identify who, what, when, where,
how, and why (Be specific)

25. List actions/recommendations you have and/or will be taking to prevent future injuries of this nature.

26. Did this accident/injury occur while performing duties as 27. If the the person was exposed to blood and/or body
an employee or working as a Class 2, 4, or 5 worker? fluids, have they been provided with the Blood and Bodily
Yes No Fluid packet per DOC 890.600? Yes
No
28. Was first aid rendered? 29. Was the person advised to seek medical 30. Was the person taken to a doctor?
Yes No care? Yes No Yes No
31. If exposure to a toxic substance, list type of chemical, name, and manufacturer name.

32. Was equipment defective? Yes No


33. If equipment was defective, give the time and date it was removed from service.

34. Was equipment being properly used? 35. If no, why?


Yes No
36. Are there records to show that the person was trained on 37. Please attach any additional documents connected to this
how to use this equipment? Yes No incident to this report.
38. Was required Personal Protective Equipment used? 39. If no, why?
Yes No
40. Were proper procedures followed? 41. What was the identified hazard (e.g., needle, hole in
Yes No ground, etc.)?
42. Has a work request/requisition been initiated? 43. List the work order/requisition number:
Yes No Work Order date:
QUESTIONS 44 – 46 ARE FOR ASSAULTS ONLY (DOC 830.180 Assault Benefits for Employees)
44. Was this injury a result of use of force? 45. Do you believe the person was assaulted by an individual
Yes No under the Department’s jurisdiction?
Yes No
46. Date employee was advised of assault benefits: / /
Supervisor/instructor name (Last, First, MI) Supervisor/instructor title Telephone number

Supervisor/instructor signature Date

PART III – TO BE COMPLETED BY THE SAFETY OFFICER WITHIN 7 CALENDAR DAYS


(If delayed, an advance copy will be sent to Human Resources)
➢ Ensure all information is legible, filled in, and correct
➢ Investigate/review and identify what factors caused the incident
➢ Distribute form accordingly and submit to Risk Management database
What action can be taken to prevent this type of event?

Primary causative factor

Corrective Action Plan

Safety Officer name Safety Officer signature Date

The contents of this document may be eligible for public disclosure. Social Security Numbers are considered confidential information and
will be redacted in the event of such a request. This form is governed by Executive Order 16-01, RCW 42.56, and RCW 40.14.
Distribution: ORIGINAL - Safety Officer COPIES - Human Resources, Reporter, Correctional Industries Manager (if applicable)
DOC 03-133 (Rev. 11/08/21) Page 2 of 2 DOC 420.205, DOC 420.385, DOC 600.025,
DOC 830.180, DOC 830.200, DOC 890.000, DOC 890.095, DOC 890.600

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