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Contractor's Choice Agency

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Founded by Josh Cotner in 2005 • 20+ Years Experience • National Producer Number 8608479

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Post-Accident Injury Investigation

Document and investigate an employee injury, accident or near miss. If anyone is in immediate danger, call 911 first.

Call 844-967-5247

The purpose of this investigation is accident prevention, not assigning blame.

Complete as much as you can. Section 6 applies only when spray foam chemicals, coatings, solvents or cleaners were involved.

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Reporting a workplace injury claim instead? Use the work comp claim report form.

Don't fill this out if you're human:

1. Incident Information

Date of Incident

Time of Incident

Date Reported

Job Name / Project

Jobsite Address

City / State

Employee Injured

Employee Job Title / Position

Supervisor / Crew Leader

Investigator

Weather Conditions, if applicable

Work Area

AtticCrawlspaceWall cavityRoofInteriorExteriorShop/WarehouseVehicle/TrailerOther

2. Type of Incident

Type of Incident — check all that apply

Slip / Trip / FallFall from ladderFall from scaffold/platformStruck by objectCaught in / betweenCut / lacerationBurnChemical exposureEye exposureSkin exposureInhalation / respiratory exposureSpray foam injection injuryEquipment or hose-related injuryElectrical incidentVehicle accidentLifting / strain / overexertionHeat-related illnessConfined-space-related incidentFire / explosionProperty damageNear missOther

3. Injury Information

Body Part(s) Injured

Nature of Injury

Was first aid provided

YesNo

If yes, by whom

Was outside medical treatment required

YesNo

Medical Provider / Facility

Was emergency transportation required

YesNo

Did the employee leave work because of the injury

YesNo

Was the employee placed on restricted duty

YesNo

Was the employee hospitalized

YesNo

Did the incident result in lost work time

YesNo

4. Employee's Description of What Happened

What task was the employee performing immediately before the incident?

Describe exactly what happened, in the employee's own words whenever possible:

What happened immediately after the incident?

5. Supervisor / Investigator Description

Describe the sequence of events leading to the incident. Include relevant equipment, materials, environmental conditions, work procedures, and employee actions.

6. Spray Foam / Chemical Exposure Investigation

Chemical / Product Involved

Manufacturer

Component:☐ A-Side / Isocyanate☐ B-Side / Resin☐ Solvent / Cleaner☐ Coating☐ Other

Type of Exposure

InhalationSkinEyesInjection / high-pressure exposureIngestionSpill / splashOther

Was the Safety Data Sheet available at the jobsite

YesNo

Was required ventilation operating

YesNoN/A

Was the employee inside the designated spray area

YesNo

Was anyone without required PPE inside the restricted area

YesNo

7. Personal Protective Equipment

What PPE was required for the task?

Personal Protective Equipment — check all that apply

Supplied-air respiratorFull-face respiratorHalf-mask respiratorSafety glassesGogglesFace shieldChemical-resistant glovesProtective suit / coverallsHard hatSafety footwearFall protectionHearing protectionOther

Was the required PPE being worn

YesNoPartially

If no or partially, explain:

Was the PPE in good condition

YesNo

Was the employee trained in proper PPE use

YesNo

If respiratory protection was required, was the employee using the assigned respirator

YesNoN/A

8. Equipment Involved

Equipment / Tool

Manufacturer / Model

Equipment condition before incident

GoodDamagedDefectiveUnknown

Was equipment being used for its intended purpose

YesNo

Was a machine guard or safety device involved

YesNoN/A

Was the safety device functioning properly

YesNoN/A

Was equipment pressure involved

YesNo

Was lockout/tagout required

YesNoN/A

Was lockout/tagout performed

YesNoN/A

Equipment removed from service following incident

YesNo

9. Jobsite Conditions

Jobsite Conditions — check all that apply

Poor housekeepingTrip hazardWet/slippery surfacePoor lightingExcessive heatCold conditionsLimited ventilationRestricted accessConfined work areaUnprotected openingImproper ladder setupScaffold/platform issueElectrical hazardChemical contaminationImproper material storageHose or cord across walking areaExcessive noiseOther

Describe relevant conditions:

10. Training and Procedures

Was there an established procedure for the task

YesNo

Was the employee trained on the procedure

YesNo

Was the employee authorized to perform the task

YesNo

Was the employee following the established procedure

YesNo

Was a pre-job safety meeting / toolbox talk conducted

YesNo

Was a Job Hazard Analysis / Job Safety Analysis completed

YesNoN/A

If procedure or training issues contributed to the incident, explain:

11. Witnesses

Witness #1 Name

Phone / Contact

Witness Statement:

Witness #2 Name

Phone / Contact

Witness Statement:

12. Contributing Factors

Employee / Work-Practice Factors

Procedure not followedProcedure unclearEmployee not trainedInadequate trainingImproper PPEPPE not usedImproper tool/equipment useRushingFatigueDistractionImproper lifting techniqueUnsafe body positionOther

Equipment / Material Factors

Equipment failureEquipment damageImproper maintenanceHose failureExcessive pressureChemical leak/spillIncorrect chemical/materialMissing safety deviceOther

Jobsite / Management Factors

Poor housekeepingInadequate supervisionInadequate planningHazard not identifiedInsufficient staffingWork area congestionInadequate ventilationInadequate fall protectionInadequate job hazard analysisOther

13. Root Cause Analysis

Why did the incident happen?

What underlying condition, process, training issue, equipment issue, or management-system failure allowed the incident to occur?

Could this incident have been prevented

YesNo

If yes, how?

14. Corrective Actions

Completed Date

RetrainingToolbox safety meetingRevise work procedureUpdate JHA/JSAReplace or repair equipmentImprove PPE requirementsImprove ventilationImprove housekeepingInstall guardingImprove fall protectionChange chemical-handling procedureIncrease supervisionCompany-wide safety communicationOther

15. Photos and Supporting Documentation

Photos and Supporting Documentation — check all that apply

Incident scene photographsEquipment photographsEmployee statementWitness statement(s)Safety Data SheetJHA/JSATraining recordsPPE recordsEquipment inspection recordsMedical / first-aid documentationOther

Were photographs taken before the scene was disturbed

YesNo

16. Required Follow-Up

Does this incident require additional employee training

YesNo

Does this incident require a company-wide safety meeting

YesNo

Does an existing policy or procedure need to be revised

YesNo

Does equipment need to remain out of service pending inspection

YesNo

Is additional management review required

YesNo

Follow-up notes:

17. Investigation Sign-Off

Employee Name

Employee Signature

Date

Supervisor Name

Supervisor Signature

Date

Investigator Name

Investigator Signature

Date

Management Review

Management Signature

Date