Llf incident analysis report checklist
Llf incident analysis
What does this form include?
This form contains 51 sections:
This form is to be completed by the Manager and employees involved in an incident. An incident is def
Identify parties involved with the incident.
DATE & TIME OF INCIDENT Date
Department
SPECIFIC LOCATION OF INCIDENT Address
Manager
Phone Number
CONTACTS
- Was there more than one employee involved?
List all Employees involved and their demographic information
Employee's Name
Employee's Occupation
Employee's address, city, state, zip Address
Employee's Phone
Date of hire Date
Serious Incidents include: Head Injuries (loss of consciousness), Heart Attacks, Amputations, Fractur
Severity of Incident
Classification
- Drug/Alcohol screen completed
Date and Time incident was reported Date
Reported to:
Type of Incident
Nature of Incident
Initial incident reported to Senior Management: Date
Employee(s) Statement
- Were two or more employees involved?
Summary of Incident
What was (were) employee(s) doing at the time of the incident?
SEQUENCE OF EVENTS
Supporting photographs
INDICATION OF INJURIES
- WERE EMPLOYEE(s) INJURED?
INDICATION OF DAMAGE TO PROPERTY
- WAS THERE ANY DAMAGE TO PROPERTY?
List estimated costs of property damages.
WITNESSES
- WERE THERE ANY WITNESSES?
Position
Summary of Witnesses Statement
CONTRIBUTING FACTORS
Additional supporting factors
List tools, equipment, materials or chemicals used at the time of the incident.
Corrective Action Categories
List each corrective action plan associated with each corrective action category.
Corrective Action
Person(s) assigned to CAP
Additional people/resources involved to complete CAP
Describe Corrective Action Plans (CAP)
Anticipated Date to complete Date
Estimated direct costs to complete
Add photo
ANALYSIS COMPLETED BY:
DATE OF REPORT Date
OPERATIONS REVIEW
DATE OF REVIEW Date
CEO REVIEW
DATE OF CEO REVIEW Date
Use this template