REGISTRATION NUMBER:

1. NAME AND SURNAME OF THE ACCIDENT VICTIM

6. SHIFT 7. DAY OF 8. HOURS WORKED 9. EXPERIENCE IN THE 10. TRAINED IN THE
3. OCCUPATION
2. AGE 4. ANTIQUITY 5. COMPANY D/N WORK (Prior to the accident) DISCIPLINE DISCIPLINE
Yes No If No
11 DATE WHEN THE INCIDENT OCCURRED 12 DATE THE INCIDENT WAS REPORTED 13 START DATE OF THE INVESTIGATION
DAY MY YEAR HOUR DAY THIS YEAR HOUR DAY THIS YEAR HOUR

14LUGAR EXACTO DEL INCIDENTE(DAR REFERENCIAS CLARAS, CIUDAD, REGIÓN, PROVINCIA, LUGAR, COORDENADAS, KM., EJE, NIVEL, NORTE, SUR, ETC.)

15 INCIDENT CLASSIFICATION
Quasi-accident First aid (FA) Medical Treatment (MT) Restricted Work (RW) Injury with Lost Time (LTP)

Fate (FAT) Damage to the process and/or material Environmental Damage Common accident

16 TYPE OF LOSSES
Almost Loss To people (Injuries) Property damage Environmental Damage

Operational Failure Vehicle(s) Production Others

17 ACCEPTABILITY OF A RISK
ACCEPTABLE TOLERABLE UNACCEPTABLE

18 DESCRIPCION
What happened? (Describe only the facts, do not speculate about the CAUSES, do not give opinions, nor send or write subjective information that cannot be verified.)

19 INJURED BODY PART 20 TYPE OF INJURY

A2I
A2D A1 Skull Lung Contusion Fracture
A3I
A3D Front Ribs Stretching Amputation
A4
A5
A6 Face Abdomen Sprain Sickness
B3D Eye Upper back Abrasion Others
B3I
B1
B2 Nose Middle back Laceration (Specify)
B4D
B4I
Mouth Lower back Drilling Cut
Teeth buttocks Foreign Body
B6D B5D Chin Pelvis Thermal Burn
B6I
B13
B5I Neck English Chemical Burn
B7D
B7I
B14 Clavicle Leg 21 TYPE OF CONTACT
B8D Shoulder Hip Hit by Noise
B8I
B9D Arm Knee Hit against Toxic Substances
B9I
B10D Elbow Calf Trapped inside Objects
B11D B12I B10I B15I
B12D
B11I
B15D Forearm Ankle Trapped over strangers
C1D
C1I Doll Leg Trapped between
C2D C2I Hand Toes Slip
C3D
C3I Thumb 1 Others (specify) Fall to the same level
C4I Finger 2 Fall to a lower level
C4D
C5I Finger 3 About effort
C5D
C11D C11I Finger 4 Contact with electricity
C10D
C9D
C10I
C9I
Finger 5 Extremetemperatures
C6D
C8D C7D C7I C8I C6I Chest Caustics / Acids
22 VEHICULAR ACCIDENT/ PROPERTY DAMAGE 23 ENVIRONMENT
* COMMITTED INSURANCE IF NO * COMMITTED INSURANCE IF NO Spill
* TIPO DE VEHÍCULO * TYPE OF VEHICLE Uncontrolled download
* YEAR * YEAR Others
* PLACA * LICENSE PLATE
* OWNER * OWNER Affected Environment

* LICENSE TYPE * TYPE OF LICENSE

* FECHA DE VENCIMIENTO * Expiration Date Type of Material
* VEHICLE DOCUMENTS UP TO DATE YES NO * VEHICLE DOCUMENTS UP TO DATE YES NO Spilled Volume

Vol. Recuperado

Contaminated body of water

24 ESTIMATED LOSS (US$)
x < 1000 1000 to 10000 10000 to 100000 100,000 to 1M 1M
 CAUSAL ANALYSIS
25 IMMEDIATE CAUSES
Substandard Act Substandard Condition Describe the substandard acts and/or conditions that exist:
Operate equipment without authorization/ Training Inadequate protection and barriers SUBSTANDARD ACT:
Failure to notice inadequate and improper EPP
Failure to assure Defective Tools / Equipment / Materials
Operar a velocidad inadecuada Inadequate warning system
Make the security devices inoperable Overcrowded / Restricted Work Area
Remove security devices Danger of explosion and/or fire
Use of defective equipment Poor order and cleanliness
Use of inappropriate equipment Environmental hazard
Failure to use PPE Exposure to noise SUBSTANDARD CONDITION:
Inadequate loading Exposure to extreme temperatures
Inadequate storage Exposure to radiation
Inadequate task position Inadequate or excessive lighting
Equipment maintenance in operation Inadequate ventilation
Jokes Others (specify)
Not following the procedures
Others (specify)

26 BASIC CAUSES
Personal Factors Work Factors Describe the substandard acts and/or conditions that exist:
Inadequate physical/physiological capacity Inadequate leadership/supervision PERSONAL FACTORS:
Inadequate mental/psychological capacity Inadequate engineering
Physical or physiological tension Inadequate acquisition
Mental or psychological tension Inadequate maintenance
Lack of knowledge Inadequate tools/equipment
Lack of skill Inadequate work standards
Inadequate motivation Excessive wear and tear WORK FACTORS:
Others (specify) Abuse or mistreatment

Inadequate ergonomic design

Others (specify)

27 Corrective Measures
DATE
DATE STATUS
DESCRIPTION OF THE MEASURE TO PREVENT RECURRENCE RESPONSIBLE PROGRAMMED
EXECUTED (R/ P /E)
A
1.-

2.-

3.-

4.

5.-

6.

Attach an additional sheet, if necessary. R=Realizada , P=Pendiente, E= En Ejecución

28 Recommendations / Suggestions from the Higher Level Administration

Indicate Name/Position/Date

The following information is attached:

Affected/Testimony Statement Sketches / Plans Training log Initial instruction / Formal

Work permit Procedures / Plans Maintenance Log Medical Report

Photographs Others specify

30 PREPARED BY: REVIEWED BY: APPROVED BY V.B. OF SSOMA

Name: Nombre: Nombre: Company
Cargo: Cargo: Cargo:
Company Company Company
Fecha: 00 oct 2000 Fecha:00 oct 2000 Fecha: 00 oct 2000
Original:Gerencia SST MARIA LORENA S.A., 1° Copia:SST Proyecto/ SST Contratista, 2°.- Copia:Investigador ,Otras: Responsables Medidas Correctivas
 Course: Risk Prevention in Work and Construction

Annex No. 1

WITNESS STATEMENT OF THE INCIDENT Fecha Declaración: __ /__ /______

Company / Contractor / Sub-Contractor Fecha del Incidente: __ /__ /______

What happened, what were you doing at the time of the incident, what were the work instructions that were given.
Write a simple account of what happened, do not speculate, write verifiable facts. We want it not to happen again.

Name:

Occupation:

I declare the following regarding the incident that occurred:

Nombre: Date 00 00 00 Company

Latin American Chamber of Security and Health at Work

 Course: Risk Prevention in Work and Construction

Annex No. 2

PHOTOGRAPHIC INFORMATION / SKETCH

Company / Contractor / Subcontractor Fecha del Incidente: __ /__ /______

North

Optional: Photographic information sheets that are necessary can be attached.

Sketch North

Prepared by:
Name: Company: Date:

Latin American Chamber of Occupational Safety and Health

 Course: Risk Prevention in Work and Construction

Annex No. 3

COMMENT / OBSERVATION / ACTION

MANAGER

Nombre: Date: Company

SITE MANAGER

Nombre: Date: __ /__ /______ Company

AREA CHIEF / SUPERVISOR

Nombre: Date: Company

HEAD OF SECURITY, OCCUPATIONAL HEALTH AND ENVIRONMENT

Name: Date: __ /__ /______ Company

FSST-011

Latin American Chamber of Safety and Health at Work