Shanahan Engineering
policy
reporting
information
Date: Report No.
Time:

Employee:
Name: Date of Birth:
Sex: Job Title:
Home Address: Home Phone:

Accident Category:
Employee Injury, Illness or Fatality
Property Damage
Near Miss Accident
Explosion or Fire
 Serious Accident
Chemical Spill or Release
Vehicle Accident
Other:

Accident Information:
Accident Date: Accident Location:
Accident Time:
Shift: Business Phone:
Injuries:
First Aid Only Lost Time Projected Days Lost:
Was Proper PPE used? Yes No Any Problems with PPE? Yes No
If yes Describe :

Brief Description of Accident (Who, What, Where, When and Why?)

Detailed Sequence of Events:


Analysis of Accident Causes:
Job Unaware of Hazard
Low level of job skill
Influence of Illness
Tried to avoid discomfort
Inattentive to Hazard
Influence of Fatigue
 Influence of Intoxicant
Physical Condition (i.e. poor vision, injury)
Unaware of Safe Method
Tried to gain or save time
Tried to Avoid extra Effort
Other:

Unsafe Conditions
– What conditions (i.e. tools, equipment, work area) contributed to accident? Check all that apply:
Worn out from normal use
Faulty Construction
Poor Housekeeping
Equipment not Inspected
Unsafe Design
Exposed to extreme temp
Inadequate Maintenance
Work area congested
Abuse of Misuse of Equipment/Tools
Exposure to vibration
Tampering with Equipment
Inadequate Illumination
Other:
 

Description of Root Cause(s):

Corrective Action Plan
Corrective Actions Planned Check all that Apply:
Improve Equip Design
Improve PPE Used
Install guard or safety device
Improve Housekeeping
Repair Equipment
 Modify materials used
Discipline of Person(s) Involved
Retraining of Person(s) Involved
Modify Work Procedures
 
Describe Corrective Actions:

Schedule, Milestone and Follow up:
    Projected Completed
Corrective Action: Responsible Person: Date Yes Date

Distribution (Check all applicable boxes):
Site Manager
Project Manager		 EHS Manager
Other Services Manager

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