OESCO - OKLAHOMA ELECTRICAL SUPPLY CO.

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INCIDENT REPORT

Property Damage:

Fire/Explosion:

Injury:

Illness:

Incident Date:*

Incident Time:*

Location of Incident:*

Weather Conditions:

Employee Name:*

Employee Classification:

Customer/Company Name:*

Task Being Performed:

Was this task addressed within the daily hazard analysis?(THA)

No Yes

If no explain:

Was Post Accident Drug Screen Submitted ?

No Yes

If no why not ?

Was this Task part of your normal job activities ?

No Yes

If no explain why below:

List Equipment, Tools and PPE Being Used:

Incident Description: (Describe in detail how the incident occurred with personal and equipment involved.)

Incident Response: (Describe immediate response activities after the incident occurred.)

Injured employee information

Was employee injured ?

No Yes

If yes answers questions below:

List Part of body injured:

Type of injury sustained:

Was injury first aide only ?

No Yes

If no where was employee treated:

Was the employee hospitalized ?

No Yes

Was Post Accident Drug screen submitted ?

No Yes

If no why not ?

Communication:(List persons contacted - internal and external)

Date:

Time:

Person Contacted:

Root Cause

Why did this event happen?

What was the employee doing at the time of the incident?

Did this task need to take place?

No Yes

If no explain why below:

Was this task listed on the pre-task plan ?

No Yes

If no explain why below:

What other steps could have been listed in the task to prevent this incident from happening:

Was the right tool used for the job ?

No Yes

If no explain why below:

Was the tool inspected before use ?

No Yes

If no explain why below:

Was training needed and not given ?

No Yes

If no explain why below:

Was this incident reported immediately ?

No Yes

If no explain why below:

Has this happened before ?

No Yes

If yes explain when and where below:

Brief employee statement below:

Was there a quality or sourcing issue ?

No Yes

If yes explain why below:

Was the employee in a rush ?

No Yes

If yes explain why below:

Root Cause & Corrective Actions: (Identify actions, responsible person and targets)

Other Team Members Involved:

Name:

Title:

Name:

Title:

Name:

Title:

Name of person filling out report:

Title:

Date & Time of Completed Report:

Date:

Time: