INCIDENT INVESTIGATION POLICY AND PROCEDURES · INCIDENT INVESTIGATION POLICY AND PROCEDURES ......

- 1 – Prepared by Maria C. Sandoval, County Safety Officer, Implemented on 03/11/2011

COUNTY OF MONTEREY County Administrative Office

Human Resources and Employment Services Division Office of Risk Management and Benefits

INCIDENT INVESTIGATION POLICY AND PROCEDURES

IIPP – 19.0


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COUNTY OF MONTEREY

INCIDENT INVESTIGATION PROCEDURES/POLICY

POLICY NO: IIPP-19.0

County of Monterey Incident Investigation Procedures / Policy pursuant to CalOSHA §3203(a) (5) of the Injury and Illness Prevention Program: “Include a procedure to investigate occupational injury or occupational illness.”


Policy..…………………………..………………………………………………………………………………. 5

Purpose..…………………………………..……………………………………………………….………....... 5

Introduction..………………………………………..………………..…………………………………………. 5

Responsibility………………………………………………………………..…………………………............ 5

Definitions…………………………………………………………..…………………………………………… 6

Conducting an Incident Investigation………………………….…………………………….………………. 8

Safety Incident Investigation SOP……………………………..…………………………………………….. 9

Incident Investigation Action Table………………………………………………………………..…………. 14

Incident Investigation Checklist………………………………………………………………….…………… 15

First Aid Incident (Non-medical)……………………………………………………………..............First Aid Incident (Medical)…………………………………………………………………………… Recordable Incidents (Medical).……………………………………………………………………...Reportable Injury (Serious/Fatal)…………………………………………………………………….

15151616

APPENDIX A Safety & Loss Control - Incident Investigation Report Form…………........................... 19

APPENDIX B Incident Witness Statement……………………………………………………..…………. 25

APPENDIX C Fatality / Serious Injury Telephone Report………………………………..……………… 27

APPENDIX D §342 Reporting Fatalities and Serious Injuries.……………………...…………............. 28

APPENDIX E Vehicle Accident Review Procedures .……………………...…………………............... 31

APPENDIX F Vehicle Accident Supervisor Checklist…………………………………………................ 32

APPENDIX G Vehicle and Property Damage Incident Report……………………………….………..… 33

APPENDIX H Driver’s Report of Accident…………………………………………………………………. 35

APPENDIX I DMV SR-1 1A Form………………………………………………………………………..…. 37

APPENDIX J Worker’s Compensation Procedures-Supervisor Checklist………...…………............... 39

APPENDIX K Worker’s Compensation Procedures-Employee’s Checklist…….…………….............. 40

APPENDIX L Worker’s Compensation / Incident Investigation Flow Chart….……………….............. 41

APPENDIX M DWC-1…………………………………………………………………….…………….……. 43

APPENDIX N Modified Work Activity Form…………………………………………………………….….. 47

APPENDIX O Incident Log…………………………………………………………………………….……. 49

APPENDIX P Safety Representative Contact List………………………………………….…………….. 50

APPENDIX Q Department Head Contact List…………………………...………………......................... 51

APPENDIX R Guide for Identifying Causal Factors………………………………………………............ 52

APPENDIX S Plan Revision History………………………………………………………………............. 64

TABLE OF CONTENTS


Incident Investigation Policy and Procedure

POLICY

This is the County of Monterey policy for incident investigation. It provides information and guidance on the process of an investigation which is to be used by County departments in preparing individualized programs. The policy identifies documentation, communication and training necessary to ensure thorough incident investigations. This policy sets procedures for the minimum standards for all County departments. Individual departments may implement more stringent standards. Copies of department-prepared programs are to be provided to the Risk Management/Safety Section upon request, and are to be included as part of the Injury and Illness Prevention Plan (IIPP).

PURPOSE

Title 8, California Code of Regulations, General Industry Safety Orders, Section 3203 requires an investigation and review of accidents and incidents resulting, or close to resulting, in occupational injury, occupational Illness, or occupational exposure to hazardous substance or agents.

INTRODUCTION

Among the first responses by a supervisor to an incident is to begin an incident investigation immediately and submit a preliminary report within 24 hours. The focus must be to place priority on learning as much as possible about what happened, and to identify means to prevent similar occurrences in the future.

RESPONSIBILITY

The County Safety Officer is responsible for the following:

• Administering the County’s Incident Investigation Plan / Policy

• Reviewing incident investigation reports to ensure that departments are conducting investigations according to the six-step process.

• Assisting individual departments with incident investigations.

• Investigating all CALOSHA reportable incidents (within 8 hours - injuries that result in hospitalization for over 12 hours, amputation, disfigurement and all fatalities.

• Providing training to all new supervisors on the County’s incident investigation procedures.


Department Heads are responsible for:

• Designating Incident Investigator(s)

• Ensure that designated Incident Investigators and supervisors are trained on County of Monterey Incident Investigaion Plan/Policy.

• Ensure that Incident Invesigators and/or supervisors conduct and document investigations for all incidents.

• Develop a practice wherein investigation reports are reviewed on a regular basis by department management, County Safety Officer, safety committees and other appropriate individuals.

Supervisors and Designated Incident Investigators are responsible for:

• Attending Incident Investigation trainings.

• Conducting, or collaborating with, incident investigations into all occupational illnesses/injuries/exposure incidents, near miss or hazardous situations that occur within their area of responsibility using the Safety & Loss Control – Incident Investigation Report Form (see Appendix A) and the six step process within 24 hours. Maintain a log of all incidents.

• Follow up on recommendations made as a result of an incident investigation and measure its effectiveness.

Employees are responsible for:

• Reporting all illnesses, injuries, exposure incidents, property damage, near misses, and hazardous situations immediately or before the end of their shift.

• Completing the employee section of the Safety & Loss Control – Incident Investigation Report Form (see Appendix A) when injured, regardless of how minor or serious the injury may be.

• Participating in the incident investigation.

Temporary Employees are responsible for:

• Reporting all illnesses, injuries, exposure incidents, property damage, near misses, and hazardous situations immediately before the end of their shift.

• Completing the employee section of the Safety & Loss Control – Incident Investigation Report Form (see Appendix A) when injured, regardless of how minor or serious the injury may be.

• Participating in the incident investigation.


• Referring to temporary agency’s worker’s compensation procedures.

DEFINITIONS

Incident: Any accident or near accident that happens at work – near miss, hazard observation, chemical spill or release, environmental, fire/explosion, illness, injury, exposure, product damage, property damage, security, vehicle DOT, vehicle non-DOT, workplace violence. Injury: A visual or non-visual injury that causes pain or discomfort to the employee, temporary worker, contractor, vendor or visitor.

In-house 1st Aid Injury: An injury where 1st aid is rendered and the employee, temporary worker, contractor, and/or vendor do not require professional medical attention. Medical Non-recordable Injury: An injury where employee receives professional medical attention and the following treatment is rendered:

• Flushing the eye to remove a foreign object,

• Dressing application to a 1st degree burn, cut or wound

• Negative x-rays,

• Over the counter medication

• One dose prescription sample,

• Tetanus shot.

Medical Recordable Injury: An injury where employee receives professional medical attention and the following treatment is rendered:

• The removal of an embedded foreign object through a surgical procedure • Stitches

• Prescription medication

• More than one physical therapy treatment

• Being treated for an infected wound

• Receiving treatment for 2nd degree burn or worse

• Employee to return to restricted duty or placed on total temporary disability

• X-rays are positive


Property Damage: An incident where monetary loss is incurred due to property or product damage to a company, employee, contractor, vendor and/or visitor. Near Miss: Or Near Hit is an incident where the potential of injury or property damage to company, employee, contractor, vendor and/or visitor exists. Reportable Incident (Serious/Fatal): An incident resulting in a serious or fatal injury to an employee, temporary worker, contractor, vendor and/or visitor. According to section 330(h), Title 8, California Administrative Code a "Serious injury or illness" means any injury or illness occurring in a place of employment or in connection with any employment which requires inpatient hospitalization for a period in excess of 24 hours for other than medical observation or in which an employee suffers a loss of any member of the body or suffers any serious degree of permanent disfigurement, but does not include any injury or illness or death caused by the commission of a Penal Code violation, except the violation of Section 385 of the Penal Code, or an accident on a public street or highway.

§ 342 Reporting Fatalities and Serious Injuries: See Appendix E

CONDUCTING AN INCIDENT INVESTIGATION

A primary tool to use in an effort to identify and recognize the areas responsible for incidents is a thorough and properly completed incident investigation. The investigation shall be initiated immediately following the incident and a preliminary written report submitted to Risk Management within 24 hours, following the incident. Investigations shall be conducted using the Safety and Loss Control – Incident Investigation report form (Appendix A). A thorough investigation will adequately identify the cause(s) of the accident or near-miss occurrence.

Incident investigations shall be conducted by trained individuals, and with the primary focus of understanding why the accident or near miss occurred and what actions can be taken to preclude recurrence.


SAFETY INCIDENT INVESTIGATION SOP

The six-step process for conducting an incident investigation involves the following:

Step 1 – Secure the accident scene

The first step in conducting an incident investigating is to secure the scene immediately using cones, tape or guards, and then to establish who will be part of the investigation team:

Incident Analysis Team Makeup

• Supervisor

• An engineer and/or maintenance supervisor

• Safety Representative/coordinator

• Occupational health/environmental personnel

Step 2 – Collect facts about what happened

Gathering facts and documenting the causes of incidents provide departments with resources that will help prevent costly accidents and injuries in the future. The methods for documenting are as follows:

• Taking pictures

• Taking samples

• Drawing sketches of the scene

• Taking measurements

• Gathering training records.

• Gathering maintenance records.

• Interviewing

o Victim(s) or Involved employees

o Supervisor

o Co-workers

o Witnesses

o First responders


o EMT’s

o Police

o Other investigators

Interviewing the Victims or Involved Employee(s): • Put the worker at ease

• Do not attempt to interview the employee if he/she is emotionally upset. Wait

until the employee is stable.

• Conduct the interview at the scene of the incident.

• Ask for the involved employee’s version of the incident. Let him/her tell it without interrupting for questions the first time.

• Ask any necessary questions. Avoid “why” type questions and do not be

judgmental or criticize. Make sure the following questions are answered:

• Paraphrase. Repeat the story back to the involved employee, as you understand it. After the employee has finished their story of the incident, say: “Okay what I hear you saying is…” then tell the story as you understand it. Finish off with, “Is my understanding of what happened correct?”

• Close the interview on a positive note – Prevention.

• Have the involved employee complete the Employee Section of the Safety &

Loss Control – Incident Investigation Report Form (see Appendix A).

• One investigator should stay with the employee to assure all appropriate questions are answered on this form.

Interview any identified witnesses. Use the same techniques for the witness, as you do for the involved employee:

• Have the witness fill out the Incident Witness Statement form (Appendix B).

• Get names, locations, and phone numbers for all individuals on the scene: Both victim(s) and witness(es).

What happened?

The investigation should describe the event that prompted the investigation: an injury to an employee, an incident that caused a down time, damaged material or any other


conditions recognized as having a potential for losses or delays. Try to ascertain exactly what happened.

Step 3 – Develop the sequence of events

• Develop the sequence of events in chronological order: What happened before during and after the incident? The focus of the chronology should be solely on what happened and what actions were taken. List alternatives when the status cannot be definitely established because of missing or contradictory information.

• List conditions or circumstances which deviated from normal, no matter how insignificant they may seem.

• List all hypotheses for the causes of the incident based on these deviations.

Step 4 – Determine the causes

The investigation should identify all the facts surrounding the occurrence:

• What caused the situation to occur? • Who was involved? • Was/were the employee(s) qualified to perform the functions involved in the

accident or near miss? • Were employee(s) adequately trained in the correct procedures? • Did employee(s) have the skills to perform the task? • Were proper operating procedures established for the task involved? • Were procedures followed, and if not, why not? • Where else might this or a similar situation exist, and how it can be corrected? • Was there anything at the incident scene that indicated a lack of housekeeping or

order that contributed to the incident? • Was the physical layout or design of the facility/worksite and its contents

adequate for the job that needed to be done? • Were there adequate procedures and rules developed to deal with this process

or task? • Could the incident have been avoided? What could have been done differently? • Was Personal Protective Equipment (PPE) available to the injured employee(s)? • Did the employee(s) recognize that a hazard existed? • Did the employee(s) use the proper equipment to do the job? • Was the injury an exacerbation of/or due to a previous injury, illness or a current

health condition? • Did environmental conditions contribute to the accident i.e.:

o Temperature extremes

o Hazardous materials


o Water

o Noise

o Lighting, etc.

Use Appendix S, Guide for Identifying Causal Factors and for Providing Corrective Actuions to assist you with the task of identifying all facts (causes that lead to the incident).

Step 5 – Recommend improvements

What should be done?

The person(s) conducting the investigation must determine which aspects of the operation or processes require additional attention. It is important to note that the purpose here is not to establish blame, but to determine what type of constructive action can eliminate the cause(s) of the incident.

Usually, making recommendations for corrective actions and system improvements follow in a rather straightforward manner from the cause(s) that were determined. A recommendation for corrective action and system improvement will contain three parts:

• The recommendation, which describes the actions and improvements to be taken to prevent recurrence of the incident.

• The name of the person(s) or position(s) responsible for accomplishing actions and improvements.

• The correction date(s). By when the corrections are expected to be completed.

Action already taken to reduce or eliminate the exposures being investigated should be noted, along with those remaining to be addressed. Any interim or temporary precautions should also be noted. Any pending corrective action and reason for delaying its implementation should be identified.

Corrective action should be identified in terms of not only how it will prevent a recurrence of the accident or near miss, but also how it will improve the overall operation. This will assist the investigator in selling his/her solutions to management. The solution should be a means of achieving not only accident control, but also total operation control.

Additionally, if you have a safety and health committee within your department, its members should review investigations of all incidents and near-miss incidents to assist in recommending appropriate corrective actions to prevent a recurrence.

Step 6 – Write the report


The sole purpose of incident investigations is to identify the basic and root causes of the incident:

• What could have been done differently? • What changes should be made (remedial action) to eliminate the potential for

similar incidents by means of: Engineering controls, change in procedures or the need to wear Personal Protective Equipment (PPE).

• Check Job Safety Analysis (JSA)

A thorough and well-written investigation report will help identify causes and needed corrections, and help determine why incidents occur, where they happen, and whether there are any incident trends. Such information is critical to preventing and controlling hazards and potential incidents.

Follow-up on any leads obtained during the investigation.

• Prior work orders • Interview indirect witnesses. • Check Job Safety Analysis (JSA)

Complete the Safety & Loss Control - Incident Investigation Report Form (Appendix A) .

• Meet with the involved employee to assist in answering all of the sections of this report.

After all documents have been completed, copies of all attachments have been added to the incident report (i.e. training records, SOPs, JSAs, Safety Operating Manuals, follow up training records or work orders, etc.) submit a copy of the packet to the Safety Officer. Addendums to investigation shall also be forwarded to the Safety Officer.

Incident Investigation Follow-Up

After the investigation is performed and the causes of the incident have been determined, the supervisor shall take steps to ensure that the same type of incident does not reoccur. Supervisors shall monitor the workplace and work practices to ensure that the selected remedial action is effective.


INCIDENT INVESTIGATION CHECKLIST

When a person is injured, the supervisor shall obtain medical help for the victim, protect other employees from injury if a hazard still exists and take immediate action to correct an existing hazard.

First Aid Incident (non-medical)

Assess injury Administer 1st Aid If trained to do so.) Give employee the Employee section of Safety and Loss Control – Incident

Investigation Report form (Appendix A); ask if employee would like to see a doctor. If so, offer the DWC-1. (Appendix M) (It is not necessary to give out the DWC form for First aid incidents with small cuts, which require a Band-Aid.)

Secure scene Take pictures Gather all documents that pertain to the incident investigation such as employee and

witness incident report, employee training documents, maintenance reports, etc.: Employee section of Safety and Loss Control – Incident Investigation Report form (Appendix A) from injured or involved employee and witnesses.

Log incident (see Appendix O) Fill out the Supervisor section of the Safety and Loss Control – Incident Investigation

Report Form (Appendix A) Note: The sequence of events portion needs to be written by supervisor or leading investigator after having gathered all documents, taken verbal witness statements and collecting all written witness statements and other reports. (You may not simply use the written statement from the employee to satisfy the requirement to complete this section.)

File documentation at department level. First Aid Incident (Medical)

Assess Injury Administer 1st Aid (if trained to do so). Supervisor or safety representative: Secure scene (barricade area until pictures,

sketches, samples, and notes of incident have been taken). Provide the DWC-1 Form (Appendix M) and Employee section of Safety and Loss

Control – Incident Investigation Report form (Appendix A) to employee. Ask witnesses to fill out the Incident Witness Statement report. (Appendix B) Log Incident (Appendix O) and call the County’s Third Party Administrator. Gather all documents that pertain to the incident investigation such as employee and

witness incident report, employee training documents, maintenance reports, etc.: See Incident Investigation SOP

Fill out the Supervisor section of the Safety & Loss Control - Incident Investigation Report Form (Appendix A). Note: The sequence of events portion needs to be written by supervisor or leading investigator after having gathered all documents,


taken verbal witness statements and collecting all written witness statements and other reports. (You may not simply use the written statement to satisfy the requirement to complete this section.)

Submit DWC-1, and preliminary Safety and Loss Control – Incident Investigation Report Form to Worker’s Compensation Coordinator and Risk Management within 24 hours.

Submit completed incident Investigation reports (with all attachments) to Worker’s Compensation Coordinator and Risk Management as soon as investigation is complete.

Recordable Incidents (Medical)

Assess Injury Administer 1st aid (if trained to do so) Notify Management (Incident Investigation Action Table) of serious injury. Have one other Supervisor or safety investigation member secure scene and take

pictures (this can be done while injured person is taken to get medical treatment.) Provide employee the DWC Form (Appendix N) and Employee Report of Incident

(Appendix B) Ask witnesses to fill out the Incident Witness Statement report (Appendix B) Log Incident (see Appendix O) and call the County’s Third Party Administrator. Call at least one other trained Safety Investigation Member (Trained to conduct

Incident Investigations) in addition to Supervisor to be part of the investigation (see enclosed list under Safety Representative/Incident Investigator Contact List – Appendix P.)

Initiate Incident Investigation: Gather all documents that pertain to the incident investigation such as employee and witness incident report, employee training documents, maintenance reports, etc.: See Incident Investigation SOP

Fill out the Safety & Loss Control - Incident Investigation Report Form (Appendix A). The first section of this document must be completed by the injured employee. The remaining sections of this document must be completed by the supervisor or Safety Representative. Note: The sequence of events portion needs to be written by supervisor or leading investigator after having gathered all documents, taken verbal witness statements and collecting all written witness statements and other reports. (You may not simply use the written statement to satisfy the requirement to complete this section.)

Submit DWC-1 and preliminary Safety and Loss Control – Incident Investigation Report Form to Worker’s Compensation Coordinator and Risk Management within 24 hours.

Submit all other incident Investigation reports to Worker’s Compensation Coordinator and Risk Management as soon as investigation is complete.

Reportable Incidents (Serious/Fatal)

Assess the injury.


Immediately (within 1 hours of incident) notify Department Head and Risk Management/Safety Officer (see Incident Investigation Action Table) of serious injury.

Have one other Supervisor or safety investigation member secure scene and take pictures (this can be done while injured person is taken to get medical treatment.)

If nonfatal incident provide DWC-1 to injured worker. (See Appendix M) Ask witnesses to fill out the Incident Witness Statement report of Injury. (Appendix

B) Log Incident (see Appendix O) and call the County’s Third Party Administrator. Call the Safety Officer and one other trained Safety Investigation Member (Trained

to conduct Incident Investigations) in addition to Supervisor to be part of the investigation (see Appendix P, Safety Representative / Incident Investigator Contact List.)

Initiate Incident Investigation: Gather all documents that pertain to the incident investigation such as employee and witness incident report, employee training documents, maintenance reports, etc.

Fill out the Safety & Loss Control - Incident Investigation Report Form (Appendix A). The County Safety Officer must complete this document. (Sequence of events must thoroughly state what happened before, during and after the incident including events after employee was treated at the medical facility.)

Submit DWC-1 and preliminary Safety and Loss Control – Incident Investigation Report to Worker’s Compensation Coordinator and Risk Management within 24 hours.

Submit all other incident Investigation reports and investigation addendums to Worker’s Compensation Coordinator and Risk Management as soon as investigation is complete.



This section to remain blank.


Department: Name of Person Investigating Incident: Location (Department) Code:

Date Investigation was initiated:

Incident Information Section I

Primary type of incident:

Injury Illness Chemical Spill or Release Environmental Fire Explosion

(select one)

Hazard Observation Near Mishap Property Damage Security Workplace Violence

Vehicle Non-DOT Vehicle DOT Other

OSHA Recordability of Injury/Illness (*OSHA Recordable)

First Aid Medical

Restricted Workday*

Lost Workday* Fatality* N/A

This section to be completed for all Injuries or Illnesses by injured employee or employee reporting an injury/property damage involving a member of the public: Does the incident involve a County employee Yes No Other Explain:____________________________________ *If more than one injured party, complete information below separately for each injured party; add additional pages as necessary. Date of Incident:

Time of Incident Time Employee Began Work:

Date Incident was Reported: Date Last Worked:

Injured Person(s) Address: Injured Person(s) Full Name:

Phone Number: Street City State ZIP

Injured Person(s) Date of Birth: Male Female

Injured Person(s) Date of Hire:

Job Title: Hours Worked/Week Days Worked/Week Hours Worked/Day

Injured Person(s) Time on Task (hours): Job/Task Injured Person(s) Years of Experience in Current Job

Department where event or exposure occurred:

Exact Location of Incident (Number, Street, City, Zip): Equipment (including PPE), materials and chemicals the employee was using when event or exposure occurred: Specific activity the employee was performing when event or exposure occurred:

What caused the incident? (Use additional paper if needed.)

List all witnesses:

Who else was involved?

What could have been done to prevent Incident? (Use additional paper if needed.)

Describe what part of your body was affected and the symptoms you presently have:

On the diagrams that follow mark an (X) on the places you have a visible injury. Circle the area of discomfort:

Injured Person’s Signature:

Date:

Front Back

Appendix A Safety and Loss Control Incident Investigation Report


Section II - This remaining sections to be completed by the Supervisor or Incident Investigator: Employment Status: Salary Continuation:

Yes No Paid for Day of Injury?

Yes No Lost work days: Yes No First full day disabled:

Date last worked:

Date DWC-1 Provided to employee: __________ Type of Employer: County Government Facility Condition

Normal Project Work Routine Maintenance Shutdown Maintenance Upset

Claim Authorization Number (ENTER number provided by LM Intake Personnel): ________________________________ Information About the Physician or Other Health Care Professional

Name of Physician or other Health Care Professional: If treatment was given away from the worksite, where was it given?

Facility Street City State ZIP

Treated in an emergency room? Yes No

Hospitalized overnight as an in-patient? Yes No

County authorized facility? Yes No

Supervisor’s Signature:

Date:

How injury/Illness occurred. Sequence of Events (Describe what happened before, during and after the incident, what part of the body was injured, what property was damaged, any tools, materials, chemicals being used and/or environment condition at the time of the incident. Use additional sheets if necessary.) Do not copy/paste the employees’ written statement. Use all data gathered to develop sequence of events. Primary Type of Contact: (select all that apply)

A. Absorption B. Bodily Reaction C. Caught In, Under or Between D. Exposure to, Contact with

E. Inhalation, Swallowing F. Overexertion (lifting) G. Repetitive Motion H. Rubbed or Abraded

I. Slip, Trip, Fall J. Struck Against/Struck By K. Temperature Extremes L. Other______________


Section III - Causal Analysis (see Guide for Identifying Causal Factors and Corrective Actions) Behaviors: (select all that apply)

1. Authority to Operate Equipment 2. Awareness of Surroundings 3. Clothing (other than P.P.E.) 4. Driver Actions 5. Drugs or Alcohol 6. Equipment Operator Actions 7. Failure to Secure 8. Grip or Hold 9. Horseplay or Fighting 10. Intentional Act/Sabotage 11. Lifting, pushing, or pulling 12. Loading or stacking 13. Lockout / Tagout

14. Mixing or combining of substances 15. Mobile Radio/Cell Phone Use 16. Need for Assistance 17. Operating Speed 18. P.P.E 19. Placement or Storage 20. Positioning for Task 21. Safe work practices or rules 22. Safety Devices 23. Servicing Equipment in Operation 24. Use of Equipment 25. Use of equipment or tools 26. Warning or Instruction 27. Other _____________________

Conditions: (select all that apply) 28. Environmental Conditions (gases, dusts, smoke,

fumes) 29. Equipment Failure 30. Exposure to cold temperatures 31. Exposure to hot Temperatures 32. Fire / Explosion 33. Guards or Barriers 34. Housekeeping 35. Illumination 36. Labeling 37. New or Modified Equipment 38. New or Modified Procedure

39. Noise 40. Protective Equipment 41. Radiation 42. Tools/equipment availability 43. Ventilation 44. Vibration 45. Visibility 46. Walking or Working surface 47. Warning Systems 48. Weather Conditions 49. Workspace Conditions (congested or restricted

access/egress) 50. Other_______________________

Write a brief description for each box checked above in the Causal Analysis section. You may use the Guide for Identifying Causal Factors and Corrective Actions (i.e. Awareness of Surroundings – Employee tripped on the parking block In the parking lot. The incident occurred at 3:30pm on a normal sunny day. Employee was reading a memo while walking to his car. He was not attentive to his surroundings and in the process tripped over the parking block.)


Basic or Root Causes: (select all that apply) 51. Abuse or misuse 52. Employee knowledge 53. Employee Skill 54. Engineering or Design 55. Inspections 56. Maintenance 57. Management Systems 58. Mental Stress or Fatigue 59. Mental or Psychological Capability 60. Motivation

61. Physical Capability 62. Physical Stress or fatigue 63. Procurement/Purchasing 64. Risk Assessment 65. Supervision or Leadership 66. Tools, Equipment, or Materials 67. Training 68. Retraining 69. Wear and Tear 70. Work Standards or Procedures 71. Other________________________

Write a brief description for each box checked above. You may use the Guide for Identifying Causal Factors and Corrective Actions (i.e. Training – The department has not provided training to employee on slip/trip and fall for more than a year.)

Section IV – Corrective Actions Corrective Actions (actions short term, intermediate, and long term (i.e. 1. Train all employees on slip/trip and fall. 2. Ensure to include Slip/Trip and Fall training as part of an annual refresher tailgate

meeting.)

By who 1. John Doe 2. Jane Doe

By when 1. 7/25/08 2. 7/25/08

Section V – Investigation Review and Approval Incident Investigator Date

Department Safety Representative Date

Supervisor’s Signature Date

Division Manager/Director’s Signature Date

Department Head’s Signature (for all incidents with restricted work or more serious) Date

County Safety Officer’s Signature (for all incidents with restricted work or more serious) Date

CAO’s Signature (all incidents involving a fatality) Date


Incident Witness Statement Witness Name: Job Title: Department:

Date of Statement: Date of Incident: Time of Incident:

Type of Incident:

Property Damage Near Miss Injury Fatality Chemical Spill

Name of person(s) involved: Department/Employer Job Title

State exactly what you saw, heard and /or physically sensed (i.e., felt, smelled or tasted) and what you

observed before, during and after the incident. For example, Begin with where people were, what they

were doing, the condition of equipment, operations being performed, noises you heard, and smells you

detected when you came onto the scene.*

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

_________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

________________________________________________________

If you were at the incident scene when it happened, list the names of everyone you saw.*

____________________________________________________________________________________

____________________________________________________________________________________

_______________________________________________________________ (Use other side of

document or additional paper if you need more writing space or if you would like to draw a diagram.)*

The above statement is a complete compilation of my understanding of the incident. I understand that this is a confidential statement, which I agree not to share without the expressed permission of the County of Monterey of by Court order. Witness Signature___________________________________ Date:_____________________

APPENDIX B

Distribution List: □ Employee Incident File □ Division Manager □ Department Head □ Risk Managment


Employee Name:

Address: Phone Number:

Fatality/Serious Injury Telephone Report Per: §342. Reporting Work-Connected Fatalities and Serious Injuries

TYPE OF INCIDENT: � Employee-Related Fatality � Non-Work Related Fatality � Employee Serious Injury � Non-Work Related Fatality � County Contractor Fatality � Other Employer Fatality � County Contractor Serious Injury � Other Employer Fatality Date of Incident:

Time of Incident:

Department:

Report Completed by: Department Address: Phone Number:

Accident Location:

Job title:

Nature of Injury:

Location where injured employee(s) were moved to:

List of emergency services and law enforcement agencies summoned to the site:

Description of Incident: (Ask about who was at the scene, how victim was discovered, type of emergency care provided, if victim was taken to hospital or deceased at the scene, was a company vehicle used. Use additional paper as needed)

Notifications (within an hour of incident): � Department Head

� CAO � Assistant CAO HR � Assistant CAO Budget � County Counsel � Risk Manager � Safety Officer

CalOSHA Phone: (510) 794-2521 Fax: (510) 794-3889 � Environmental Manager � Intercare � Other:

Comments:

APPENDIX C


Chapter 3.2. California Occupational Safety and Health Regulations (CAL/OSHA) Subchapter 2. Regulations of the Division of Occupational Safety and Health

Article 3. Reporting Work-Connected Injuries

§342. Reporting Work-Connected Fatalities and Serious Injuries.

(a) Every employer shall report immediately by telephone or telegraph to the nearest

District Office of the Division of Occupational Safety and Health any serious injury or

(b) illness, or death, of an employee occurring in a place of employment or in connection with any employment.

Immediately means as soon as practically possible but not longer than 8 hours after the employer knows or with diligent inquiry would have known of the death or serious injury or illness. If the employer can demonstrate that exigent circumstances exist, the time frame for the report may be made no longer than 24 hours after the incident. Serious injury or illness is defined in section 330(h), Title 8, California Administrative Code. (b) Whenever a state, county, or local fire or police agency is called to an accident involving an employee covered by this part in which a serious injury, or illness, or death occurs, the nearest office of the Division of Occupational Safety and Health shall be notified by telephone immediately by the responding agency. (c) When making such report, whether by telephone or telegraph, the reporting party shall include the following information, if available: (1) Time and date of accident. (2) Employer's name, address and telephone number. (3) Name and job title, or badge number of person reporting the accident. (4) Address of site of accident or event. (5) Name of person to contact at site of accident. (6) Name and address of injured employee(s). (7) Nature of injury. (8) Location where injured employee(s) was (were) moved to. (9) List and identity of other law enforcement agencies present at the site of accident.

APPENDIX D (1 of 2)


(10) Description of accident and whether the accident scene or instrumentality has been altered. (d) The reporting in (a) and (b) above, is in addition to any other reports required by law and may be made by any person authorized by the employers, state, county, or local agencies to make such reports. NOTE: Authority cited: Sections 60.5, 6308 and 6409.1, Labor Code. Reference: Sections 6302(h), 6307, 6308, 6313 and 6409, Labor Code. HISTORY 1. New Article 3 (Section 342) filed 8-1-74 as an emergency; effective upon filing (Register 74, No. 31). 2. Certificate of Compliance filed 10-25-74 (Register 74, No. 43). 3. Amendment filed 2-28-79; effective thirtieth day thereafter (Register 79, No. 9). 4. Amendment of subsection (a), repealer of subsection (d) and relettering of subsection (e) to subsection (d) filed 12-5-84; effective thirtieth day thereafter (Register 84, No. 49). 5. Amendment of subsection (a) and new subsection (c)(10) filed 12-5-85; effective thirtieth day thereafter (Register 85, No. 49). 6. Amendment of subsection (a) filed 5-22-87; operative upon filing (Register 87, No. 22). (p. 8.24.6.2.1) 7. Amendment of subsection (a) filed 8-2-96; operative 9-1-96 (Register 96, No. 31).

APPENDIX D (2 of 2)


Distribution List: □ Employee Incident File □ Division Manager □ Department Head □ Risk Management □ CAO

APPENDIX E



APPENDIX F


APPENDIX G


Distribution List: □ Employee Incident File □ Division Manager □ Department Head □ Risk Managment

APPENDIX H



APPENDIX I (1 of 2)


APPENDIX I (2 of 2)


County of Monterey

Worker’s Compensation Procedures What to do when an Injury First Occurs

Supervisor’s Checklist Within 24 hours of notice of an industrial injury or illness:

Give the DWC-1 to injured employee.

Provide the employee with a copy of the handout Facts for Injured Workers.

Supervisor/Incident Investigator: Have employee complete the Employee Section of the Safety & Loss Control Injury and Illness Report form.

Supervisor/Incident Investigator: Complete the remaining sections of the Safety & Loss Control Injury and Illness Report form.

Supervisor: Enter all pertinent information in the Incident Log.

Advise the employee to notify you if the condition worsens and a doctor is seen, or if there is time lost from work due to this injury. If a doctor is seen or the employee loses any time from work:

Request that employee return the completed DWC-1 form.

Complete the emloyer’s section of the State of California Workers’ Compensation Claim Form (DWC-1) (Ensure that dates on line items 11 and 12 are entered).

Access Intercare website at www.intercareins.com to prepare and submit 5020 form.

Provide all information requested online by Intercare using the information on the completed 5020.

If the employee is seeking medical treatment, provide employee with Medical Referral and Modified Work Activity Form, to take to the doctor.

Check employee’s file to see if he/she has a designated physician. If so, advise employee he/she should be treated by designated physician. If not, provide employee with list of Authorized Treatment Facilities and determine which would best suit the employee’s situation.

Call the clinic and let them know a Monterey County employee is coming to have their injury/illness treated.

Fax a copy of the DWC-1, Safety and Loss Control Incident Investigation Report Form, and injured employee’s Job Description to Intercare Holdings at (916) 781-5700 or e-mail scanned copies to: [email protected]. Send original or copies of the following forms to Lucy Raney in Risk Management: Safety & Loss Control Injury and Illness Report, DWC-1.

APPENDIX J

http://www.intercareins.com/�


APPENDIX K

County of Monterey Worker’s Compensation Procedures

What to do when an Injury First Occurs Employee’s Checklist

Before the end of your shift on day of incident, notify your manager or supervisor in the event of a work related injury or illness and comply with your supervisor’s direction concerning procedures for return to work.

On same day of first Doctor visit for illness, make sure your treating physician completes the Modified Work Activity Form and return form to the designated person in your department. Designate to use or not use accruals for lost time.

If made available, accept or reject, in writing, an appropriate offer of modified or alternative work assignment (see sample of Modified Work Agreement letter and sample of Modified Work Alternative letter that may be found in the County of Monterey website as follows: http://www.co.monterey/workcomp/emplchklst.htm. (Note that both samples are Microsoft Word files)

Keep your manager or supervisor informed as to your medical recovery status.

On a regular basis (at least monthly) provide appropriate medical information, reports or releases to the designated person in your department. Employees must use his/her accruals for all medical/therapy appointments.

Modified Duty Work Assignment should not exceed a 90 day period without a change in job duties” For more information please contact your WC Coordinator that may be found in the following link: http://www.co.monterey/workcomp/pdfs/WorkersCompCoordinatorList.pdf

Inform your manager or supervisor if any problems arise during the course of your temporary modified work assignment.

Note: The establishment of a temporary modified work assignment and/or the signing of a modified task agreement does not constitute the establishment of a permanent job nor does it eliminate the injured worker’s regularly assigned position or assigned job tasks.

Rejecting modified job duty offer could result in cancellation of TTD payments.

http://www.co.monterey/workcomp/pdfs/modactivform.pdf�

http://www.co.monterey/workcomp/pdfs/modactivform.pdf�

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http://www.co.monterey/workcomp/pdfs/WorkersCompCoordinatorList.pdf�

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County of Monterey Worker’s Compensation / Incident Investigation Flow Chart

What to do When an Injury First Occurs

APPENDIX L

Employee is injured on the job

Complete Sections I and II of the Safety and Loss Control Incident Investigation Report form.

Direct employee to designated County Medical Provider or employee’s designated physician (non-emergency) Provide employee with County Modified Work Activity form and Medical Referral to take to doctor.

Administer First Aid if trained to do so. Provide Employee the DWC-1 and “Facts for Injured Workers” within 24 hours of knowledge of injury

Interview injured employee (when at all possible), supervisor, and any witnesses.

First Aid

Medical

Serious Injury

Immediately inform Dept. Head and County Safety Officer or designee.

Dial 9-911 Advice employee to notify you if the condition worsens and a doctor is seen, or any time is lost from work due to the injury

Conduct an Incident investigation using the Safety & Loss Control and Incident Investigation Report form within 24 hours of incident.

Access Intercare’s website to prepare and submit the 5020 form at www.intercareins.com. Use the information from Sections I and II of the Safety and Loss Control Incident Investigation Report form to report the claim.

Refer to Return to Work Procedures

Follow up on recommendations to prevent similar incident.

Hospitalization/ Amputation/ Disfigurement/ Fatality

http://www.intercareins.com/�


Workers’ Compensation Claim Form (DWC 1) & Notice of Potential Eligibility Formulario de Reclamo de Compensación para Trabajadores (DWC 1) y Notificación de Posible Elegibilidad

If you are injured or become ill, either physically or mentally, because of your job, including injuries resulting from a workplace crime, you may be entitled to workers’ compensation benefits. Attached is the form for filing a workers’ compensation claim with your employer. You should read all of the information below. Keep this sheet and all other papers for your records. You may be eligible for some or all of the benefits listed depending on the natureof your claim. If required you will be notified by the claims administrator, who is responsible for handling your claim, about your eligibility for benefits. To file a claim, complete the Employee” section of the form, keep one copy and give the rest to your employer. Your employer will then complete the “Employer” section, give you a dated copy, keep one copy and send one to the claims administrator. Benefits can’t start until the claims administrator knows of the injury; so complete the form as soon as possible. Medical Care: Your claims administrator will pay all reasonable and necessary medical care for your work injury or illness. Medical benefits may include treatment by a doctor, hospital services, physical therapy, lab tests, x-rays, and medicines. Your claims administrator will pay the costs directly so you should never see a bill. For injuries occurring on or after 1/1/04, there is a limit on some medical services. The Primary Treating Physician (PTP) is the doctor with the overall responsibility for treatment of your injury or illness. Generally your employer selects the PTP you will see for the first 30 days, however, in specified conditions, you may be treated by your predesignated doctor. If a doctor says you still need treatment after 30 days, you may be able to switch to the doctor of your choice. Special rules apply if your employer offers a Health Care Organization (HCO) or after 1/1/05, has a medical provider network. Contact your employer for more information. If your employer has not put up a poster describing your rights to workers’ compensation, you may choose your own doctor immediately. Within one working day after an employee files a claim form, the employer shall authorize the provision of all treatment, consistent with the applicable treating guidelines, for the alleged injury and shall continue to provide treatment until the date that liability for the claim is accepted or rejected. Until the date the claim is accepted or rejected, liability for medical treatment shall be limited to ten thousand dollars ($10,000). Disclosure of Medical Records: After you make a claim for workers' compensation benefits, your medical records will not have the same privacy that you usually expect. If you don’t agree to voluntarily release medical records, a workers’ compensation judge may decide what records will be released. If you request privacy, the judge may "seal" (keep private) certain medical records. Payment for Temporary Disability (Lost Wages): If you can't work while you are recovering from a job injury or illness, you will receive temporary disability payments. These payments may change or stop when your doctor says you are able to return to work. These benefits are tax-free. Temporary disability payments are two-thirds of your average weekly pay, within minimums and maximums set by state law. Payments are not made for the first three days you are off the job unless you are hospitalized overnight or cannot work for more than 14 days.

Si Ud. se lesiona o se enferma, ya sea física o mentalmente, debido a su trabajo, incluyendo lesiones que resulten de un crimen en el lugar de trabajo, es posible que Ud. tenga derecho a beneficios de compensación para trabajadores. Se adjunta el formulario para presentar un reclamo de compensación para trabajadores con su empleador. Ud. debe leer toda la información a continuación. Guarde esta hoja y todos los demás documentos para sus archivos. Es posible que usted reúna los requisitos para todos los beneficios, o parte de éstos, que se enumeran, dependiendo de la índole de su reclamo. Si se requiere, el/la administrador(a) de reclamos, quien es responsable del manejo de su reclamo, le notificará a usted, lo referente a su elegibilidad para beneficios. Para presentar un reclamo, complete la sección del formulario designada para el Empleado”, guarde una copia, y déle el resto a su empleador. Entonces, su empleador completará la sección designada para el “Empleador”, le dará a Ud. una copia fechada, guardará una copia, y enviará una al/a la administrador(a) de reclamos. Los beneficios no pueden comenzar hasta, que el/la dministrador(a) de reclamos se entere de la lesión, así que complete el formulario lo antes posible. Atención Médica: Su administrador(a) de reclamos pagará toda la atención médica razonable y necesaria, para su lesión o enfermedad relacionada con el trabajo. Es posible que los beneficios médicos incluyan el tratamiento por parte de un médico, los servicios de hospital, la terapia física, los análisis de laboratorio y las medicinas. Su administrador(a) de reclamos pagará directamente los costos, de manera que usted nunca verá un cobro. Para lesiones que ocurren en o después de 1/1/04, hay un límite de visitas para ciertos servicios médicos. El Médico Primario que le Atiende-Primary Treating Physician PTP es el médico con toda la responsabilidad para dar el tratamiento para su lesion o enfermedad. Generalmente, su empleador selecciona al PTP que Ud. verá durante los primeros 30 días. Sin embargo, en condiciones específicas, es posible que usted pueda ser tratado por su médico pre-designado. Si el doctor dice que usted aún necesita tratamiento después de 30 días, es posible que Ud. pueda cambiar al médico de su preferencia. Hay reglas especiales que son aplicables cuando su empleador ofrece una Organización del Cuidado Médico (HCO) o depués de 1/1/05 tiene un Sistema de Proveedores de Atención Médica. Hable con su empleador para más información. Si su empleador no ha colocado un poster describiendo sus derechos para la compensación para trabajadores, Ud. puede seleccionar a su propio medico inmediatamente. El empleador autorizará todo tratamiento médico consistente con las directivas de tratamiento applicables a la lesión o enfermedad, durante el primer día laboral después que el empleado efectúa un reclamo para beneficios de compensación, y continuará proveyendo este tratamiento hasta la fecha en que el reclamo sea aceptado o rechazado. Hasta la fecha en que el reclamo sea aceptado o rechazado, el tratamiento médico será limitado a diez mil dólares ($10,000). Divulgación de Expedientes Médicos: Después de que Ud. presente un reclamo para beneficios de compensación para los trabajadores, sus expedientes médicos no tendrán la misma privacidad que usted normalmente espera. Si Ud. no está de acuerdo en divulgar voluntariamente los expedientes médicos, un(a) juez de compensación para trabajadores posiblemente decida qué expedientes se revelarán. Si Ud. solicita privacidad, es posible que el/la juez “selle” (mantenga privados) ciertos expedientes médicos. Pago por Incapacidad Temporal (Sueldos Perdidos): Si Ud. no puede trabajar, mientras se está recuperando de una lesión o enfermedad relacionada con el trabajo, Ud. recibirá pagos por incapacidad temporal. Es posible que estos pagos cambien o paren, cuando su médico diga que Ud. está en condiciones de regresar a trabajar. Estos beneficios son libres de

APPENDIX M (1 of 3)


Workers’ Compensation Claim Form (DWC 1) & Notice of Potential Eligibility Formulario de Reclamo de Compensación para Trabajadores (DWC 1) y Notificación de Posible Elegibilidad

Return to Work: To help you to return to work as soon as possible, you should actively communicate with your treating doctor, claims administrator, and employer about the kinds of work you can do while recovering. They may coordinate efforts to return you to modified duty or other work that is medically appropriate. This modified or other duty may be temporary or may be extended depending on the nature of your injury or illness. Payment for Permanent Disability: If a doctor says your injury or illness results in a permanent disability, you may receive additional payments. The amount will depend on the type of injury, your age, occupation, and date of injury. Vocational Rehabilitation (VR): If a doctor says your injury or illness prevents you from returning to the same type of job and your employer doesn’t offer modified or alternative work, you may qualify for VR. If you qualify, your claims administrator will pay the costs, up to a maximum set by state law. VR is a benefit for injuries that occurred prior to 2004. Supplemental Job Displacement Benefit (SJDB): If you do not return to work within 60 days after your temporary disability ends, and your employer does not offer modified or alternative work, you may qualify for a nontransferable voucher payable to a school for retraining and/or skill enhancement. If you qualify, the claims administrator will pay the costs up to the maximum set by state law based on your percentage of permanent disability. SJDB is a benefit for injuries occurring on or after 1/1/04. Death Benefits: If the injury or illness causes death, payments may be made to relatives or household members who were financially dependent on the deceased worker. It is illegal for your employer to punish or fire you for having a job injury or illness, for filing a claim, or testifying in another person's workers' compensation case (Labor Code 132a). If proven, you may receive lost wages, job reinstatement, increased benefits, and costs and expenses up to limits set by the state. You have the right to disagree with decisions affecting your claim. If you have a disagreement, contact your claims administrator first to see if you can resolve it. If you are not receiving benefits, you may be able to get State Disability Insurance (SDI) benefits. Call State Employment Development Department at (800) 480-3287. You can obtain free information from an information and assistance officer of the State Division of Workers' Compensation, or you can hear recorded information and a list of local offices by calling (800) 736-7401. You may also go to the DWC web site at www.dir.ca.gov. Link to Workers’ Compensation. You can consult with an attorney. Most attorneys offer one free consultation. If you decide to hire an attorney, his or her fee will be taken out of some of your benefits. For names of workers' compensation attorneys, call the State Bar of California at (415) 538-2120 or go to their web site at www.californiaspecialist.org.

impuestos. Los pagos por incapacidad temporal son dos tercios de su pago semanal promedio, con cantidades mínimas y máximas establecidas por las leyes estatales. Los pagos no se hacen durante los primeros tres días en que Ud. no trabaje, a menos que Ud. sea hospitalizado(a) de noche, o no pueda trabajar durante más de 14 días. Regreso al Trabajo: Para ayudarle a regresar a trabajar lo antes posible, Ud. debe comunicarse de manera activa con el médico que le atienda, el/la administrador(a) de reclamos y el empleador, con respecto a las clases de trabajo que Ud. puede hacer mientras se recupera. Es posible que ellos coordinen esfuerzos para regresarle a un trabajo modificado, o a otro trabajo, que sea apropiado desde el punto de vista médico. Este trabajo modificado, u otro trabajo, podría extenderse o no temporalmente, dependiendo de la índole de su lesión o enfermedad. Pago por Incapacidad Permanente: Si el doctor dice que su lesión o enfermedad resulta en una incapacidad permanente, es posible que Ud. reciba pagos adicionales. La cantidad dependerá de la clase de lesión, su edad, su ocupación y la fecha de la lesión. Rehabilitación Vocacional: Si el doctor dice que su lesión o enfermedad no le permite regresar a la misma clase de trabajo, y su empleador no le ofrece trabajo modificado o alterno, es posible que usted reúna los requisitos para rehabilitación vocacional. Si Ud. reúne los requisitos, su administrador(a) de reclamos pagará los costos, hasta un máximo establecido por las leyes estatales. Este es un beneficio para lesiones que ocurrieron antes de 2004. Beneficio Suplementario por Desplazamiento de Trabajo: Si Ud. no vuelve al trabajo en un plazo de 60 días después que los pagos por incapcidad temporal terminan, y su empleador no ofrece un trabajo modificado o alterno, es posible que usted reúne los requisitos para recibir un vale no-transferible pagadero a una escuela para recibir un nuevo entrenamiento y/o mejorar su habilidad. Si Ud. reúne los requisitios, el administrador(a) de reclamos pagará los costos hasta un máximo establecido por las leyes estatales basado en su porcentaje del incapicidad permanente. Este es un beneficio para lesiones que ocurren en o después de 1/1/04. Beneficios por Muerte: Si la lesión o enfermedad causa la muerte, es posible que los pagos se hagan a los parientes o a las personas que vivan en el hogar, que dependían económicamente del/de la trabajador(a) difunto(a). Es ilegal que su empleador le castigue o despida, por sufrir una lesión o enfermedad en el trabajo, por presentar un reclamo o por atestiguar en el caso de compensación para trabajadores de otra persona. (El Codigo Laboral sección 132a). Si es probado, puede ser que usted reciba pagos por perdida de sueldos, reposición del trabajo, aumento de beneficios, y gastos hasta un límite establecido por el estado. Ud. tiene derecho a estar en desacuerdo con las decisiones que afecten su reclamo. Si Ud. tiene un desacuerdo, primero comuníquese con su administrador(a) de reclamos, para ver si usted puede resolverlo. Si usted no está recibiendo beneficios, es posible que Ud. pueda obtener beneficios de Seguro Estatal de Incapacidad (SDI). Llame al Departamento Estatal del Desarrollo del Empleo (EDD) al (800) 480-3287. Ud. puede obtener información gratis, de un oficial de información y asistencia, de la División estatal de Compensación al Trabajador (Division of Workers’ Compensation – DWC), o puede escuchar información grabada, así como una lista de oficinas locales, llamando al (800) 736-7401. Ud. también puede ir al sitio electrónico en el Internet de la DWC en www.dir.ca.gov. Enlácese a la sección de Compensación para Trabajadores. Ud. puede consultar con un(a) abogado(a). La mayoría de los abogados ofrecen una consulta gratis. Si Ud. decide contratar a un(a) abogado(a), sus honorarios se tomarán de sus beneficios. Para obtener nombres de abogados de compensación para trabajadores, llame a la Asociación Estatal de Abogados de California (State Bar) al (415) 538-2120, ó vaya a su sitio electrónico en el Internet en www.californiaspecialist.org.

APPENDIX M (2 of 3)

http://www.dir.ca.gov/�


State of California Department of Industrial Relations DIVISION OF WORKERS’ COMPENSATION

WORKERS’ COMPENSATION CLAIM FORM (DWC 1) Employee: Complete the “Employee” section and give the form to your employer. Keep a copy and mark it “Employee’s Temporary Receipt” until you receive the signed and dated copy from your em - ployer. You may call the Division of Workers’ Compensation and hear recorded information at (800) 736-7401. An explanation of workers' compensation benefits is included as the cover sheet of this form. You should also have received a pamphlet from your employer describing workers’ compensation benefits and the procedures to obtain them. Aperson who makes or causes to be made any knowingly false

Estado de California Departamento de Relaciones Industriales

DIVISION DE COMPENSACIÓN AL TRABAJADOR

PETITION DEL EMPLEADO PARA DE COMPENSACIÓN DEL TRABAJADOR (DWC 1)

Empleado: Complete la sección “Empleado” y entregue la forma a su empleador. Quédese con la copia designada “Recibo Temporal del Empleado” hasta que Ud. reciba la copia firmada y fechada de su empleador. Ud. puede llamar a la Division de Compensación al Trabajador al (800) 736-7401 para oir información gravada. En la hoja cubierta de esta forma esta la explicatión de los beneficios de compensación al trabjador. Ud. también debería haber recibido de su empleador un folleto describiendo los benficios de compensación al trabajador lesionado y los procedimientos para obtenerlos.haga o cause que se produzca uier declaración o representación material falsa o fraudulenta con el fin de obtener o negar beneficios o pagos de compensación a trabajadores

Employee—complete this section and see note above Empleado—complete esta sección y note la notación arriba.

1. Name. Nombre. ____________________________________________Today’s Date. Fecha de Hoy. ________________________________

2. Home Address. Dirección Residencial. _________________________________________________________________________________

3. City. Ciudad. _______________________________________ State. Estado. __________________ Zip. Código Postal. ________________

4. Date of Injury. Fecha de la lesión (accidente). ________________________ Time of Injury. Hora en que ocurrió. _______a.m. ______p.m.

5. Address and description of where injury happened. Dirección/lugar dónde occurió el accidente. ____________________________________

___________________________________________________________________________________________________________________

6. Describe injury and part of body affected. Describa la lesión y parte del cuerpo afectada. _________________________________________

___________________________________________________________________________________________________________________

7. Social Security Number. Número de Seguro Social del Empleado. ____________________________________________________________

8. Signature of employee. Firma del empleado. ____________________________________________________________________________

Employer—complete this section and see note below. Empleador—complete esta sección y note la notación abajo.

9. Name of employer. Nombre del empleador. _____________________________________________________________________________

10. Address. Dirección. ________________________________________________________________________________________________

11. Date employer first knew of injury. Fecha en que el empleador supo por primera vez de la lesión o accidente._______________________

12. Date claim form was provided to employee. Fecha en que se le entregó al empleado la petición. ___________________________________

13. Date employer received claim form. Fecha en que el empleado devolvió la petición al empleador. _________________________________

14. Name and address of insurance carrier or adjusting agency. Nombre y dirección de la compañía de seguros o agencia adminstradora de

seguros.____________________________________________________________________________________________________________

15. Insurance Policy Number. El número de la póliza de Seguro. _______________________________________________________________

16. Signature of employer representative. Firma del representante del empleador. _________________________________________________

17. Title. Título. _____________________________________________18. Telephone. Teléfono. ____________________________________

Employer: You are required to date this form and provide copies to your insurer or claims administrator and to the employee, dependent or representative who filed the claim within one working day of receipt of the form from the employee. SIGNING THIS FORM IS NOT AN ADMISSION OF LIABILITY

Empleador: Se requiere que Ud. feche esta forma y que provéa copias a su compañía de seguros, administrador de reclamos, o dependiente/representante de reclamos y al empleado que hayan presentado esta petición dentro del plazo de un día hábil desde el momento de haber sido recibida la forma del empleado. EL FIRMAR ESTA FORMA NO SIGNIFICA ADMISION DE RESPONSABILIDAD

Employer copy/Copia del Empleador Employee copy/Copia del Empleado Claims Administrator/Administrador de Reclamos Temporary Receipt/Recibo Temporal

Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers’ compensation benefits or payments is guilty of a felony.

Toda aquella persona que a propósito haga o cause que se produzca cualquier declaración o representación material falsa o fraudulenta con el fin de obtener o negar beneficios o pagos de compensación a trabajadores lesionados es culpable de un crimen mayor “felonia”.

APPENDIX M (3 of 3)

7/1/04 Rev


Employee Information (to be completed by Supervisor) Medical Provider: Employee Name: Date/Time Injured: Date being sent: Job Title:

Intercare Holdings Insurance

P.O. Box 579

Roseville, CA 95661

Tel: (800) 771-5454

Fax: (916) 677-2610 Worker’s Comp Adjuster:

Brief Description of Accident: Claim Number: Physician: Please complete this form before the employee leaves the office today. Give the employee a copy for his supervisor. Fax a copy to Intercare at (916) 677-2610 Physician reviewed Job Description. Employee work status: This patient has been instructed to:

May return to Full Duty with no limitations or restrictions.

Return to Modified Work with restrictions listed below. (Please check one for each item.)

May return t work a full ____hour shift. May work ____hours of an _____hour shift.

Standing No Restrictions No Standing Limited to Hours/shift Sitting No Restrictions No Sitting Limited to Hours/shift Alternate Stand/Sit Yes No Limited to Hours/shift Walking No Restrictions No Walking Limited to Hours/shift Alternate Walk/Sit Yes No Limited to Hours/shift Bending (Back) No Restrictions No Bending Limited to Hours/shift Squatting (knees) No Restrictions No Squatting Limited to Hours/shift Reaching (upper) No Restrictions No Reaching Limited to Hours/shift Overhead Reaching No Restrictions No Reaching Limited to Hours/shift Pushing (Back) No Restrictions No Pushing Limited to Hours/shift Pulling (Back) No Restrictions No Pulling Limited to Hours/shift Driving No Restrictions No Driving Limited to Hours/shift Grasping (Hands) No Restrictions No Grasping Limited to Hours/shift Keying (Hands) No Restrictions No Keying Limited to Hours/shift Climbing No Restrictions No Climbing Limited to Hours/shift Viewing Computer No Restrictions No viewing computer Limited to Hours/shift Other Restrictions:

Weight Restriction: Employee Limited to lifting. (Choose one)

5-10 lbs 10-20lbs 20-40 lbs. 50 lbs

No Restrictions

Frequency of lifting. Lifting as indication above is limited (chose one):

Occasionally (1 – 2x/hr)

Frequently (3 – 4x/hr)

Continuously (5+ x/hr)

Other

Exposures Describe any chemical or mechanical exposure limitations:

Re-evaluation/Return to Full Duty: Employee will be re-evaluated on: Anticipated date of return to full duty:

Physician printed Name:

Physician Signature: Date:

Department: Forward a copy to Risk Management via fax at (831) 751-9597.

APPENDIX N County of Monterey

Modified Work Activity Form


Supe

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Initi

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Com

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Empl

oyee

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APPENDIX O Incident Log

Department:_____________________________


Safety Representative Contact List Name Department Phone Incident Investigator Maria Sandoval Risk Management (831) 784-5686 Yes

APPENDIX P


DEPARTMENT: DEPARTMENT HEAD: PHONE: County Administrative Office Lew C. Bauman (831) 755-5115 Budget & Analysis Vacant (831) 755-5115 Human Resources Keith Honda (831) 755-5116 Intergovernmental & Legislative Affairs Nick Chiulos (831) 755-5145 Agricultural Commissioner Eric Lauritzen (831) 759-7325 Assessor-County Clerk-Recorder (Elected) Stephen L. Vagnini (831) 755-5035 Auditor-Controller (Elected) Michael J. Miller (831) 755-5040 Building Services Tim McCormick (831) 755-5027 Clerk of the Board Gail T. Borkowski, CCB (831) 755-5066 Child Support Services Stephen Kennedy (831) 755-3200 Cooperative Extension Service Sonya Hammond (831) 759-7350 County Counsel Charles McKee (831) 755-5045 District Attorney (Elected) Dean Flippo (831) 755-5070 Elections Linda Tulett (831) 796-1499 Emergency Communications Lynn Diebold (831) 796-8880 Equal Opportunity Office Irma Ramirez-Bough (831) 755-5117 Health Public Administrator Ray Bullick (831) 755-4525 Information Technology Vacant (831) 759-6900 Library Jayanti Addleman (831) 883-7573 Military & Veterans Affairs Thomas Griffin (831) 647-7610 Natividad Medical Center Harry Weis (831) 755-4111 Parks John Pinio (831) 755-4895 Planning Mike Novo (831) 755-5025 Probation Manuel Real (831) 755-3900 Public Defender James Egar (831) 755-5058 Public Works Paul Greenway - Interim (831) 755-4800 Resource Management Agency Gene Rogers - Interim (831) 755-4879 Sheriff-Coroner (Elected) Scott Miller (831) 755-3700 Social & Employment Services Elliott Robinson (831) 755-4400 Treasurer - Tax Collector (Elected) Mary Zeeb (831) 755-5015 Water Resources Agency Vacant (831) 755-4860

APPENDIX Q Department Head Contact List


This guide has been designed to assist Incident Investigators on completing the root causes section of the Safety and Loss Control – Incident Investigation Report form. Behaviors (Select all that apply)

Causal Factors Comment (Use extra paper as needed.) Actions Recommended

Corrective Action Yes No

1. Was employee authorized to operate equipment?

Review employee training records on specific equipment. Ensure procedures identify training requirements for all employees operating equipment.

Yes No

2. Was awareness of surroundings a cause of the incident?

Review employee training records and retrain employee on job/task.

Yes No

3. Was employee wearing clothing adequate for the job?

Identify if the use of clothing or the lack of was a contributing factor and update the procedures to address this issue.

Yes No

4. Were driver actions the cause of the incident?

Review VUP and employee training records and retrain (when at fault).

Yes No

Yes No

5. Was the use of drugs or alcohol involved in the incident? Was employee provided a copy of the policy?

Review County’s Drug and Alcohol Use Policy. Review employee training records

Yes No

6. Was correct equipment, tool(s) or materials used for the job?

Specify correct equipment, tool(s) or material in job procedures.

Yes No

7. Did employee(s) know where to obtain equipment/tool(s)/material used in place of correct one?

Review procedures for storage, access, delivery, or distribution, Review job procedures for obtaining equipment, tool(s), or materials.

Yes No

8. Were substitute equipment/tool(s)/material used in place of correct one?

Provide correct equipment, tool(s), or materials. Warn against use of substitutes in job procedures and in job instruction.

Yes No

Yes No

9. Was failure to secure a contributing factor for incident? Were employee(s) trained on specific task and the hazards associated with it?

Review JSA and SOP for the task. Write a JSA if none available and train employees on securing procedures.

Yes No

Yes No

10. Did grip or hold fail? Were employee(s) trained on specific task and the hazards associated with it?

Review JSA and training on specific task. Check for step on securing grip or hold and the hazards associated when these fail. Check for audits on equipment for possible corrections.

Yes No

Yes No

11. Was horseplay or fighting one of the causes of the incident? Were employees trained on safety codes specifically on “Horseplay or Workplace Violence Prevention?”

Review Safety Codes to ensure that horseplay or fighting is included. Define horseplay in safety codes.

Yes No

Yes No

Yes No

12. Was incident caused by intentional act/sabotage. Is there a JSA for specific task? Are employees trained on type of act or sabotage?

Review security measures and policies that apply to type of act/sabotage. Update policy/procedures if necessary. Review training records of affected employees.

Appendix R Guide for Identifying Causal Factors and for Providing Corrective Actions


Causal Factors Comment (Use extra paper as needed.) Possible Corrective Actions Recommended


Yes No

Yes No

13. Was lifting, pushing or pulling one of the causes leading to the incident. Is there a JSA for specific task? Was employee trained on specific task?

Review SOPs for lifting, pushing or pulling. Write or update JSA to including hazards associated with the task/job and recommendations on how to prevent a similar incident. Train employees on revised SOP and JSA for task.

Yes No

Yes No

Yes No

14. Was unsafe loading or stacking the cause of the incident? Is there a JSA for specific task? Was employee trained on specific task?

Review procedures for loading or stacking. Write or update JSA to including hazards associated with the task/job and recommendations on how to prevent a similar incident. Train employees on task.

Yes No

Yes No

Yes No

15. Was failure to Lockout / Tag Out a contributing factor? Is there a written Lockout / Tag Out procedure? Are employee trained on Lockout / Tag Out procedures?

Review Lockout / Tag Out procedures and policy. Update policy as needed. Review employee training on lock out tag out, JSA and SOP for task/job. Train employees on updated procedures and associated hazards.

Yes No

Yes No

Yes No

Yes No

16. Was mixing or combining of substances one of the causes of the incident? Does department have a written Hazard Communication “Your Right to Know” Policy in place? Is there a JSA for specific task? Was employee(s) trained on specific task?

Review Hazard Communication, “Your Right to Know” Policy. Update if necessary. Update/write a new policy. Update/write a new JSA on specific task. Train all employees on updates and JSA.

Yes No

Yes No

Yes No

17. Was the use of mobile Radio/cell phone use a contributing factor? Is there a JSA for specific task? Was employee(s) trained on specific task?

Review JSA, Safety Codes and the Cell Phone use Policy. Review radio training procedures. Update policies and procedures as needed.

Yes No

Yes No

Yes No

18. Was the need for assistance a contributing factor that lead to this incident? Is there a JSA for specific task? Was employee(s) trained on specific task?

Review/write SOP and JSA. Include language indicating the need to get assistance for the task. Train all affected employees on new or updated SOP and JSA.




Yes No

Yes No

19. Was operating speed the cause of this incident? Was employee trained on the operation of the equipment or vehicle? For auto: Has employee been trained on Defensive Driving?

Review the SOP for equipment /VUP with employee. Provide training on proper speed. Review employee training records and retrain.

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

20. Was employee wearing proper Personal Protective Equipment (PPE)? Was appropriate PPE specified for the task or job? Was the PPE adequate for the task? Was appropriate PPE available? Did employee(s) know that wearing specific PPE was required? Did employee(s) know how to use and maintain the PPE? Was the PPE used Properly when the injury occurred?

Review methods to specify PPE requirements. Review PPE requirements, check standards, specification and certification of the PPE. Write a JSA which includes PPE requirements. Provide appropriate PPE. Review purchasing and distributing procedures. Review training procedures. Include JSA as a tool to train employees. Train affected employees on new/updated SOP and JSA.

Yes No

Yes No

Yes No

21. Placement or storage: Was/were employee(s) or equipment in correct location? Is there a JSA for specific task? Was employee(s) trained on specific task?

Review housekeeping audits. Revise to address the identification of placement and storage hazards. Write new SOP and JSA if none available. Train all affected employees on new/updated SOP and JSA.

Yes No

Yes No

Yes No

22. Was/were employee(s)’ positioning for Task the correct one? Is there a JSA for specific task? Was employee(s) trained on specific task?

Review SOP/JSA for job/task. Update SOP/JSA addressing the hazards with recommendations on how to prevent injury. Write new SOP and JSA if none available. Train all affected employees on new/updated SOP and JSA.




Yes No

Yes No

Yes No

23. Did employee follow safe work practices or rules? Does the department have written safety codes posted, available to all employees? Is there a JSA for specific task? Was employee(s) trained on specific task?

Review location safety codes, JSA and SOP. Review employee training records. Update safety code, JSA and/or SOP or write new if none available. Train employee on all of the above.

Yes No

24. Was the lack/failure of safety devices one of the leading causes of the incident?

Review audit/ inspections of equipment/location. Include equipment/location audit/inspection as part of a planned maintenance (PM). Train employee on all of the above.

Yes No

Yes No

Yes No

25. Was servicing equipment in operation one of the causes that lead to the incident? Is there a JSA for specific task? Was employee(s) trained on specific task?

Review employee training records, SOP and JSA for task. Review equipment Safety Operating Manual. Update all documents as necessary or write new SOP and JSA for task. Train or retrain employee(s) on safety hazards and how to prevent injury.

Yes No

Yes No

Yes No

26. Was the improper use of equipment or tools the cause of the incident? Is there a JSA for specific task? Was employee(s) trained on specific task?

Review employee training records, SOP and JSA for task. Review equipment or tool Safety Operating Manual. Update all documents as necessary and train or retrain employee(s) on all updates specifically on safety hazards and how to prevent injury

Yes No

Yes No

Yes No

Yes No

27. Was the lack of warning or instruction the cause of the incident/ Were warning signs posted? Is there a JSA for specific task? Was employee(s) trained on specific task?

Review employee training records on specific task/equipment/tool/machine. Check for posted warning signs. Update all documents as necessary or write new SOP and JSA for task. Train or retrain employee(s) on safety hazards and how to prevent injury.

List other causal factors attributed to behavior(s).



Corrective Action Conditions (Select all that apply)

Yes No

28. Were environmental conditions a contributing factor? (gases, dusts, smoke or fumes)

Monitor or periodically check environmental conditions as required. Check results against acceptable levels. Initiate action for those found unacceptable.

Yes No

Yes No

29. Defect in equipment, tools, or materials? Was employee(s) trained on how to identify defects in tools or materials?

Review control procedures for inspecting, reporting, maintaining, repairing, replacing, or recalling defective equipment, tools, or materials. Review training documents for affected employee(s)

Yes No

30. Did the design of the equipment/tool(s)/material create operator stress or encourage operator error?

Review human factors engineering principles. Alter equipment, tool(s) to make it more compatible with human capability and limitations. Review procurement procedures and specification. Check out new equipment and job procedures involving new equipment before putting into service. Encourage employees to report potential hazardous conditions created by equipment design.

Yes No

31. Did the general design or quality of the equipment/tool(s) contribute to hazardous condition?

Review criteria in codes, standards, specifications, and regulations. Establish new criteria as required.

Yes No

Yes No

Yes No

32. Was the exposure to cold temperatures the cause of the incident? Is there a JSA for specific task? Was employee wearing adequate clothing for the task? Was employee trained on specific task?

Review SOP/JSA for job/task. Update SOP/JSA addressing the hazards with recommendations on how to prevent injury. Write new SOP and JSA if none available. Train all affected employees on new/updated SOP and JSA.

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

33. Was the exposure to hot temperatures the cause of the incident? Does department have a written Heat Illness Prevention Plan? Was water available to employee? Was shelter provided to employee? Was employee provided breaks? Is there a JSA for specific task? Was employee trained on plan and specific task?

Review Heat Illness Prevention Plan and SOP/JSA for job/task. Update the plan and SOP/JSA to address the hazards with recommendations on how to prevent injury. Write new Heat Illness Prevention Plan, SOP and JSA if none available. Train all affected employees on new/updated plan, SOP and JSA.




Yes No

Yes No

34. Was Fire / Explosion the cause of the incident? Does the department have a written Fire Prevention Plan in place? Does the department have a written Emergency Evacuation Plan that includes fires.

Investigate what caused the fire/explosion. Review the Fire Prevention Plan and update as needed. Review and update the Emergency Evacuation Plan as needed. Retrain all affected employees on new or updated plans.

Yes No

Yes No

Yes No

Yes No

35. Was the lack of guards or barriers the cause of the incident? Were the barriers or guards removed? Were the barriers or guards broken? Were the barriers or guards not installed by the manufacturer?

Review and update SOP/JSA procedures for task to address the hazards and recommendations on how to prevent similar incident. Write new SOP and JSA if none available. Review audit/ inspections of equipment/location. Include equipment/location audit/inspection as part of a planned maintenance (PM). Train employee on all of the above.

Yes No

Yes No

Yes No

36. Was housekeeping the cause of incident? Does the department perform monthly housekeeping audits as part of a monthly PM? Have employees received training on hazards involving task?

Review Housekeeping inspection procedures. Include methods to identify hazards and recommendations on how to prevent similar incident. Initiate monthly housekeeping inspections. Include equipment/location audit/inspection as part of a planned maintenance (PM). Train affected employee(s) on all of the above.

Yes No

37. Was illumination one of the causes that lead to the incident?

Analyze lighting of location. Add more lighting as needed.

Yes No

Yes No

Yes No

38. Was the lack of or improper labeling one of the causes that lead to the incident? Chemical: Was the chemical transferred to a different container? Does the department have a written Hazardous Communication “Your right to know” Plan in place?

Chemical: Affix proper label on container. Review / update or write a new Hazardous Communication plan. Train employees on the department’s Hazardous Communication Plan and all the MSDSs for the chemicals they work with. Equipment: Check equipment for missing labels and install new ones. Write inspection checklist for employees to use prior to using the equipment.




Yes No

Yes No

Yes No

Is employee trained on the department’s Hazardous Communication plan and the MSDSs for the chemicals he/she was handling? Equipment: Does the equipment have the proper labels per the Standard Operating Manual? Do employees perform safety checks using a written checklist? Are new employees trained on Safe Operating procedures and how to perform daily inspections using the written checklist prior to initiating work and are annual refresher trainings provided to employees?

Train employees on conducting daily inspections.

Yes No

Yes No

39. Was new or modified equipment one of the causes that lead to the incident? Is there a written JSA and SOP for the use of new or modified equipment?

Review and update or write, if none on available, JSA and SOP. Address the need to follow Management of Change MOC) process. Train employees on all new equipment or modifications.

Yes No

Yes No

Did JSA and SOP identify the hazards associated with the use of the new or modified equipment? Was/were employee(s) trained on the new or modified equipment’s JSA and SOP?

Yes No

Yes No

Yes No

Yes No

40. Was a new or Modified procedure the cause of the incident? Is there a written JSA and SOP for the procedure? Did JSA and SOP identify the hazards associated with the procedure? Was/were employee(s) trained on new or modified procedure’s JSA and SOP?

Review and update or write a new, if none available, JSA and SOP. Address the need to follow Management of Change MOC) process anytime change occurs. Train employees on all procedural modifications.




Yes No

Yes No

Yes No

Yes No

41. Was noise a cause of the incident? Has equipment or operation been tested for noise levels? Was PPE available? Was employee wearing PPE? Was employee trained on donning and maintaining the PPE?

Review Hearing Loss Prevention Program. Update as needed. Review noise level audits. Review the need to wear appropriate or additional PPE. Review/update JSA for task as needed.

Yes No

Yes No

42. Was the lack of, defective or inadequate Protective Equipment the cause of the incident? Is there a written JSA and SOP for the task/job?

Assess the need for PPE. Assess procurement for PPE. Write a JSA addressing the need for PPE and ways to prevent injury. Have employees

Yes No

43. Was exposure to radiation the cause of the incident?

Review/update procedures for preventing exposure to radiation. Train all affected employees on procedures for preventing exposure to radiation to include the use and donning of personal protective equipment.

Yes No

44. Was the lack of Tools/equipment availability the cause of the incident?

Check with procurement to see when last order was placed.

Yes No

45. Was the lack of ventilation the cause of the incident?

Check PM schedule for the HVAC system. Make a plan B for addressing heat issues when HVAC system is down.

Yes No

46. Was vibration the cause of the incident?

Check PM schedule of the equipment. Train employees to report unusual vibrations.

Yes No

47. Was the lack of visibility the cause of the incident?

Provide a description of the issues relating to visibility. Provide methods to prevent future similar incident.

Yes No

48. Was the walking or working surface the cause of the incident?

Take pictures, provide a description of the walking/working surface and, if known, explain what caused the incident. If the incident was a slip, trip or fall, provide pictures of the shoes injured person was wearing at the time of incident.

Yes No

49. Was the lack of or inadequate warning systems a factor that led to the incident?

Were signs in place warning others of hazard? Take pictures of location and any signs or warning signs in the vicinity. Add new signs as needed. Train all employees on ways to identify the need to include warning systems to prevent incidents.




50. Was weather conditions a factor that led to the incident?

Provide a description of the weather conditions that were a factor that lead to the incident.

Yes No

51. Was the workspace conditions (congested or restricted access/egress) the cause of the incident?

Review audit reports for area/location where incident occurred. Make recommendations to clear area.

Yes No

Yes No

Yes No

52. Was the hazardous condition(s) recognized? (if yes, answer “a” and “b”’ if no proceed to next question. a. Was/were the

hazardous condition/s reported?

b. Was/were employee/s informed of the hazardous condition/s and the job procedures for dealing with it?

Perform job safety analysis (JSA). a. Train employees in reporting

procedures. Stress employees’ responsibility for safety.

b. Remove hazard. Review job procedures for hazard avoidance. Train employees on JSA.

List other causal factors attributed to the environment.

Basic or Root Cause Yes No

Yes No

53. Was the cause of the incident due to abuse or misuse of equipment? Was the employee trained on proper use of equipment?

Review equipment’s Safety Operating Manual. Review training records. Retrain employee on proper use of equipment.

Yes No

54. Was employee knowledge adequate?

Review training records on specific job/task. Retrain as needed.

Yes No

55. Was employee’s skill adequate for the job/task?

Review training/experience on job specific tasks.

Yes No

56. Was the engineering or design of location / equipment adequate for the job/task?

Review Safety Operating Manual. Check to see if guards were removed. Check to see if equipment was manufactured without guards. Check for emergency stop buttons and their location.

Yes No

57. Does department conduct scheduled inspections that would identify hazards in that area.

Review inspection records for location where incident occurred.

Yes No

58. Was the lack of maintenance a factor that led to the incident?

Review PM (planned maintenance) schedule to ensure that maintenance is performed regularly.




Yes No

Yes No

Yes No

59. Management systems Is there a written Safety Operating Procedure that includes training. Does the job/task have a JSA to help identify the hazards and ways to prevent injury at every step of the job? Does the job/task/location include an audit system to ensure that all areas of safety are covered: • Housekeeping • Machine guarding • Audits • Training • Disciplinary Action • Retraining

Review JSA’s, Standard Operating Procedures, Safety Operating Manual(if available. Audit reports, disciplinary actions taken (if any). Require that all audit systems be Implemented for location/equipment. Make additional recommendations for improvement, as needed.

Yes No

60. Was mental stress or fatigue a factor that led to the incident?

Request that employee , supervisor and any known witness provide a narrative with sequence of events (in chronological order) that caused the mental stress or fatigue.

Yes No

61. Was mental or psychological capability a factor that lead to the incident?

Request that employee , supervisor and any known witness provide a narrative with sequence of events (in chronological order) that caused the mental stress or fatigue.

Yes No

62. Was the lack of motivational factor that lead to the incident

Describe if lack of motivation was the cause of the incident

Yes No

63. Was the lack of physical capability a cause that led to the incident?

Does the department require employees to go through job placement fitness test prior to hiring?

Yes No

Yes No

64. Was physical Stress or fatigue a factor that led to the incident? Was employee working overtime at the time of incident?

Yes No

65. Was Procurement / purchasing a contributing factor that led to the incident?

Yes No

66. Had a Risk Assessment been previously performed by writing an SOP and JSA?

Review current SOP and JSAs. Update documents or write new ones if none available.




Yes No

67. Was the lack of supervision or leadership a contributing factor that led to the incident? Was injured employee trained?

Review training records for employee and supervisor. Interview injured employee and supervisor and request that they provide a sequence of events of the incident. Review audit and PM records.

Yes No

Yes No

68. Was the injured employee asked to work under unsafe conditions? Were audits and PM checks performed on equipment? How often?___________

Yes No

Yes No

Yes No

Yes No

Yes No

69. Tools, equipment or material Was injured employee using the right tool, equipment or material for the job. Was the right tool, equipment, material for the job available? Was the tool, equipment, or material in safe working order Was employee trained on safe use of tool, equipment or material?

Check tool, equipment or material employee was using. Check on procurement records to check order status. Check employee and supervisor training records.

Yes No

Yes No

70. Training Was employee trained on the job/task he/she was performing?

Review training records. Interview employee to assess his/her knowledge of the job/task he/she was performing.

Yes No

Yes No

Yes No

Yes No

Yes No

71. Wear and tear Was equipment, tool or material’s wear and tear the cause of the incident/ Is the tool, equipment or material required to be audited, inspection prior to each use? Are there written guidelines on when to purchase/order new tool, equipment or material? Is the tool, equipment or material on a PM schedule?

Check equipment, space, material for wear and tear. Review JSA or Standard Operating procedures for information regarding the tool, equipment, material’s wear and tear signs and what to do to prevent injury. Review inspection records. Review procurement records. Review PM records.




Yes No

Yes No

Yes No

72. Was there a written procedure for this job? If Yes answer a), b) and c). If no, proceed to next question. a) Did job procedures

anticipate the factors that contributed to the accident?

b) Did employee(s) receive training on job procedures?

Perform job safety analysis and develop safe job procedures a) Perform job safety analysis and

change job procedures. b) Improve job instruction. Train

employees in correct job procedures.

c) Determine why. Encourage all employees to report problems with an established procedure to

c) Did employee(s) deviate from the known job procedures

supervision. Review expectations of employees and the consequences for their actions. Counsel or discipline employee(s).

Yes No

73. Are there written procedures for conducting inspections/audits on equipment?

Review procedures, if none available recommend for department to write procedures for conducting inspections/audits for the different locations.

Yes No

74. Is existing equipment inspection/audit adequate?

Review current procedures; change frequency or comprehensiveness. Provide test equipment as required. Train employee in detecting defects and hazardous conditions. Change job procedures as required.


APPENDIX S Revision History

Date Revised By Updates

10/09/2011 Maria C. Sandoval Updated Safety and Loss Control Incident Investigation Form – added numbers to each causal factor item.

10/09/2011 Maria C. Sandoval Updated Appendix C-Fatality/Serious Injury Telephone Report form.

10/09/2011 Maria C. Sandoval Updated Appendix J Worker’s Compensatiojn Procedures-Supervisor Checklist; removed Liberty’s’s info and replaced it with Intercare’s information.

10/09/2011 Maria C. Sandoval Updated Appendix N- Modified Work Activity form; removed Liberty’s contact information and replaced it with Intercare’s inforamtion

10/09/2011 Maria C. Sandoval Updated Appendix B-Incident Witness Statement, changed the format of the form.

INCIDENT INVESTIGATION POLICY AND PROCEDURES · INCIDENT INVESTIGATION POLICY AND PROCEDURES ......

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