SUMMARY INFORMATION
General	Date:	Time:	Day:	Shift:	ID:
Injury/Illness	Auto/Property	Environment	Incident/Near Miss	Other – Attach Explanation
Haskell 1st Aid
Off Site 1st Aid
OSHA
Summary	Description of Incident. (How the Incident occurred & sequence of events. Attach additional pages, if needed. )
Primary Analysis	Direct Cause	Indirect Cause	Basic Cause	(Refer to Proximate Cause Table)
Surface Cause(s): What actions and/or conditions caused or led up to the event? (Refer to Potential Cause Matrix)
Actions:	Procedures	Tools/Equip	Protective Systems	Awareness
Conditions:	Exposure	Tools/Equip	Protective Systems	Workplace Layout
Contributing Factor(s): What Human of System Factors influenced occurrence of the event? (Refer to Root Cause Profile Chart)
Human Factors:	Capability	Condition	Behavior	Knowledge/Skill
System Factors:	Supervision	Training	Selection	Planning
Purchasing	Maintenance	Policies	Communication
The underlying cause of this event is related to:
Unsafe Condition	Unsafe Action	Management	Other – Attach Explanation
Corrective Action	Corrective Action Plan: What will be done to prevent a second Incident? (Attach additional pages, if needed.)
Re-Train	Re-Design	Re-Enforce	Other
Assigned to:	Date:
Review	Completed By
Name:	Date:
Title:	Phone:
Management Review
Safety Manager:	Date:
Project Manager:	Date:
President:	Date:
Employee Acknowledgement
Print Name
Signature:	Date:

INJURY INFORMATION
Injured Person	The following sections may contain confidential employee information, please respect the privacy of the injured person by maintaining strict control of this form
First	M.I.	Last	Claim #
SSN:	Date Hired:	DOB:
Emergency Contact:	Phone:
Schedule	Wage	Position
Apprentice
Hrs/Day	Days/Wk	Hourly	Fringe	Craft	Local	Journeyman
Did this injury/illness originate or occur during the course of current employment?	No Yes ?
Is this event related to a prior injury/illness or pre-existing condition?	No Yes ?
Is the source, cause, or validity of this injury in question or doubt?	No Yes ?
Did the injured person report this incident within 24-hrs and prior to medical treatment?	No Yes ?
List Any Witnesses
ACTIVITY	What was the employee doing just before the event? (Refer to Injury & Illness Profile)
Action:	Object:
EVENT	What actually caused the injury/illness?
Event:	Source:
INJURY	What Type of injury/illness resulted from the event?
Nature:
BODY PART	What part of the body was affected or Injured? (indicate left or right)
Head	Torso	Upper Limb	Lower Limb	Systems
TREATMENT	What level of treatment was provided?
On-Site First Aid	Off-Site First Aid	Off-Site Medical Aid	ER/9-1-1
Medical Facility Name:
Provider Name:	Phone
Address:	City	State	Zip
Treatment:
Follow Up Treatment Plan:
Released to Job of Injury?	No	Yes	Date:
Follow up Appointment?	No	Yes	Date:
Restricted Work Activity?	No	Yes	Starting Date:	Estimated # of days:
Day(s) Away from Work?	No	Yes	Starting Date:	Estimated # of days:

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POTENTIAL CAUSE LIST
List ALL Potential Surface and Contributing Factors
CODE	Category & Description (Potential Cause Matrix)
1.1	EXAMPLE Description: Taking Shortcuts – Near shift end, worker was hurrying
Description:
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Count the number of potential causes for each code

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Sequence of Events
Establish the ‘planned’ and ‘actual’ sequence of events.
Planned Activity	Actual Events
Attach JSA / STA or describe below	Describe the events leading up to the event.
Deviations from plan
Description:
Description:
Description:
Potential Severity (of this or future events)
LOW	MEDIUM	HIGH
Potential for recurrence
LOW	MEDIUM	HIGH
Preventative Controls Assigned
N/A	YES	NO
Attachments:
5-Why Analysis	Ishikawa Analysis	Apollo Cause Map & Report

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Direct Causes	Indirect Causes	Basic Causes
Struck by/against	Failure to secure	No oversight
Falls	Guarding	Poor maintenance.
Caught in/between	Improper use	Training
Exertion	Unsafe position	Policies
Contact with….	Environmental	Stress
Impact (vehicle)	Defect	Engineering
Failure to recognize	Actions	Situational awareness

ID:

Use this table to identify potential cause paths.
Surface Factors
Actions	Procedures PROCEDURES	Tools/Equip./Vehicles	Protective Systems	Awareness
1.1 Taking shortcuts	2.1 Improper use of	3.1 Failure to use PPE	4.1 Lack of Awareness
1.2 Lack of Authorization	2.2 Inappropriate for Task	3.2 Improper use of PPE	4.2 Distractions
1.3 Violation of procedure	2.3 Using Broken/Defective/Incomplete	3.3 Failure to use Protective Systems	4.3 Change in process
1.4 Using wrong procedure	2.4 Exceeding Limitations of	3.4 Removal of Protective Systems (guards)	4.4 Routine/Repetitive Activity
1.5 Improper application of procedure	2.5 Unauthorized Modification of	3.5 Using Inadequate Protective Systems	4.5 Body Position
1.6 Other	2.6 Other	3.6 Other	4.6 Other
Conditions	Exposure To	Tools/Equip./Vehicles	Protective Systems	Workplace Layout
5.1 Previously Unidentified Hazards	6.1 Broken/Defective	7.1 Inadequate Guards/Protection	8.1 Congested or Limited Space
5.2 General Environment (weather, etc.)	6.2 Inadequate	7.2 Defective Guards/Protection	8.2 Illumination/Ventilation/Sanitation
5.3 Acts of Violence	6.3 Incorrect/Wrong	7.3 Inadequate Warning Systems	8.3 Organization/Housekeeping
5.4 3rd Party Activity/Condition	6.4 Beyond Usable Service Life	7.4 Protective Devices not available	8.4 New/Unfamiliar work area
5.5 Significant External Event	6.5 Unauthorized Modification of	7.5 Exceeding Design Limitations	8.5 Access/Egress Restrictions
5.6 Other	6.6 Other	7.6 Other	8.6 Other
Contributing Factors
Human	Physical Capabilities	Physical Condition	Behavior	Skill Level
9.1 Physical Deficiency	10.1 Previous Injury/Illness	11.1 Aggressive	12.1 Lack of Skill
9.2 Sensory Deficiency	10.2 Anxiety/Stress	11.2 Overconfident	12.2 New Skill
9.3 Systemic Deficiency	10.3 Fatigue/tiredness	11.3 Negligent	12.3 Infrequent Skill
9.4 Exceeding Personal Limitations	10.4 Substance Abuse	11.4 Apprehensive	12.4 Repetitive Skill
9.5 Other	10.5 Other	11.5 Other	12.5 Other
System	Management	Training	Employee Selection	Schedule/Planning
13.1 Commitment	14.1 Need not recognized	15.1 Incomplete Background Check	16.1 Time Pressure
13.2 Chain of Command	14.2 Not Provided	15.2 Not qualified/Under qualified	16.2 Budget Pressure
13.3 Leadership/Supervision	14.3 Inadequate	15.3 Unaddressed Historical Issues	16.3 Lack of Resources
13.4 Failure to correct deficiencies	14.4 Negative Reinforcement	15.4 Substance Abuse	16.4 Accelerated Schedule
13.5 Other	14.5 Other	15.5 Other	16.5 Other
Purchasing	Maintenance	Policies/Procedures	Communication
17.1 Wrong item/part	18.1 Lack of Maintenance	19.1 Lack of Policy	20.1 Communication Barriers
17.2 Substituted item/part	18.2 Inadequate Maintenance	19.2 Inadequate Policy	20.2 Lack of Communication
17.3 Shipping Delay	18.3 Exceeded Lifespan	19.3 Lack of Policy Enforcement	20.3 Conflicting Communications
17.4 Ordering Delay	18.4 Failure to Inspect	19.4 Changes to Policy	20.4 Communication method
17.5 Other	18.5 Other	19.5 Other	20.5 Other
Responsibility:	1. Employee	2. Management	3. Other

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Use the following tables to categorize injury and illness events
What was the employee doing just before the event?
Activity	Action:	Object:
Sitting	Holding	Tool	Person/Self
Standing	Using	Equipment	Environment
Walking	Positioning	Material	Surfaces
Climbing	Unknown/Other	Structure	Unknown/Other
What actually caused the injury/illness?
Event	Event:	Source:
Struck by…	Slip/Trip/fall	Chemical	Environment
Exposure to…	Fall to lower level	Tool	Position/Motion
Contact with…	Overexertion	Vehicle/Equipment	Structures/Fixtures
Caught in/by…	Unknown/Other	Material/Debris/Waste	Unknown/Other
What Type of injury/illness resulted from the event?
Injury	Amputation	Bruise/Contusion	Foreign body/Irritation	CTS/RSI
Abrasion / Irritation	Burn-Thermal	Fracture /Dislocation	Stress/Trauma
Laceration / Puncture	Burn-Chemical	Sprain/Strain	Occ. Illness
Bite/Sting	Cold/Heat-Related	Multiple Injuries	Unknown/Other
What part of the body was affected or Injured? (indicate left or right)
Body Part	Head	Torso	Upper Limb	Lower Limb	Systems
Eyes	Chest	Shoulder	Hip	Respiratory
Ears	Abdomen	Arm	Leg	Circulatory
Nose	Upper Back	Elbow	Knee	Digestive
Mouth	Lower Back	Wrist	Ankle	Reproductive
Neck	Buttock	Hand	Foot	Nervous
Skull/Head	Groin/Pelvis	Thumb	Heel	Skeletal
Chin/Jaw	Side	Finger	Toe	Skin
Unknown/Other	Unknown/Other	Unknown/Other	Unknown/Other	Unknown/Other

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