Written witness statements: Photograph s: Maps / drawing s :
What personal protective equipment was being used (if any)?
Describe, step-by-step the events that led up to the injury. Include names of any machines, parts, objects, tools, materials
and other important details.
Description continued on attached sheets:
Step 3: Why did the incident happen?
Unsafe workplace conditions: (Check all that apply)
Safety device is defective
Tool or equipment defective
Workstation layout is hazard ous
Lack of needed personal protective equipment
Lack of appropriate equipment / tools
No training or insufficient training
Other: _______________________ ______
Unsafe acts by people: (Check all that apply)
Operating without permission
Operating at unsafe speed
Servicing equipment that h as power to it
Making a safety device inoperative
Using defective equipment
Using equipment in an unapproved way
Taking an unsafe position or posture
Distraction, teasing, horseplay
Failure to wear personal protective equipment
Failure to use the available equipment / tools
Other: _______________________ ___________
Why did the unsafe conditions exist?
Why did the unsafe acts occur?
Is there a reward (such as “the job can be done more quickly”, or “the product is less likely to be damaged”) that may
have encouraged the unsafe conditio ns or acts? Yes No
If yes, describe:
Were the unsafe acts or conditions reported prior to the incident? Yes No
Have there been similar incidents or near misses prior to this one? Yes No