MARABA AL IRAQ AL KHADRAA

Incident Investigation Report

a) This form to be completed for all job-related injuries or illnesses – regardless of extent.
b) Must be completed by supervisor within 24 hours of incident.

Name ________________________________________________________________ Job Tile _________________________________

First Middle Last
AM AM
Date of Injury: Hour: PM Time Left Work: PM Date of Birth:
Department Name Name of Supervisor Date Reported to Supervisor

Exact Location of Accident: Name of Witness:

Describe Accident (What was injured worker doing; what objects, machines o materials were involved):
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Regular Days Off Working Shift AM AM

PM to PM

Employee Signature: ________________________________________________________ Date: ___________________________

ACTION BODY PART INJURED NATURE OF INJURY

 FIRST AID CASE ONLY  HEAD  FACE  EYE  ABRASION  LACERATION  PUNCTURE
 REQUIRED DOCTOR’S CARE  NECK  BACK  CHEST  BRUISE  FRACTURE  BURN
 HOSPITALIZED  ARM  HAND  FINGER  SPRAIN/STRAIN  FOREIGN BODY  POISON OAK
 OSHA NOTIFIED  LEG  KNEE  ANKLE  COLD INJURY  HEAT NJURY  DEMATITIS
 TIME LOSS  FOOT  TOE  LOSS OF  OCCUPATIONAL
 NO INJURY/NEAR MISS  OTHER _____________________________________ CONCIOUSNESS ILLNESS
 OTHER ________________________________________

Additional Note:
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QHSE Coordinator INVESTIGATION OF CAUSE (CHECK ONE OR MORE)

Doc No. MIK-FM-21-02 Issue No. 1.0 Issue Date: 01 June 2018 Revision Date:
 MARABA AL IRAQ AL KHADRAA

Incident Investigation Report

Did you personally view the incident site? Yes  No Employee Category: Faculty  Staff  Visitor

UNSAFE ACTS UNSAFE CONDITIONS

 OPERATING WITHOUT  HORSEPLAY  IMPROPERLY GUARDED  INADEQUATE WARNING

AUTHORITY
 FAILURE TO WARN OTHERS
 OPERATING OR WORKING AT
UNSAFE SPEED
 MAKING SAFETY DEVICES
INOPERATIVE
 FAILURE TO SECURE OBJECTS
 USING UNSAFE EQUIPMENT
OR EQUIPMENT UNSAFELY
 UNSAFE LOADING, MIXING,
CARRYING
 TAKING UNSAFE POSITION OR
POSTURE
 FAILURE TO USE PERSONAL
PROTECTIVE DEVICES
 FAILURE OT OBSERVE SAFETY
REGULATIONS
 LACK OF TRAINING OR
KNOWLEDGE
 PREVENTABLE VEHICLE
ACCIDENT
 SLIPS AND FALLS
 FAILURE TO LOCK OUT/TAG
OUT
 OTHER:
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EQUIPMENT OR MACHINE SYSTEM
 DEFECTIVE TOOL OR  HAZARDOUS STORAGE OR
EQUIPMENT ARRANGEMENT
 POOR HOUSEKEEPING  HAZARDOUS DRESS OR
APPAREL
 IMPROPER LIGHTING  HAZARDOUS WORK
PROCEDURE
 IMPROPER VENTILATION  HAZARDOUES WEATHER OR
(DUST, FUMES, ETC.) ENVIRONMENT
 UNSAFE DESIGN OR  CONTACT WITH POISONOUS
CONSTRUCTION PLANTS, INSECTS, TOXIC
 SLIPPERY OR OTHER UNSAFE CHEMICALS, SKIN IRRITANTS,
SURFACE BITES, ECT.
 OTHER:
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 REASONS FOR UNSAFE ACT (Must be completed by QHSE Coordinator)

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 REASONS FOR UNSAFE CONDITION (Must be completed by QHSE Coordinator )

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 WHAT PRACTICAL CORRECTIVE ACTION WILL BE TAKEN BY QHSE COORDINATOR TO PREVENT RECURRENCE?
(Must be completed by QHSE Coordinator.) Note: The wording “be more careful” is unacceptable, as it does not
present a viable solution. If the cause is properly identified, there should be several solutions.
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QHSE COORDINATOR SIGNATURE _______________________________________________ DATE ___________________________

Doc No. MIK-FM-21-02 Issue No. 1.0 Issue Date: 01 June 2018 Revision Date: