TITLE:

ES&H Manual

 

DOCUMENT ID:

5200-T1 Incident/Notable Event/Injury Investigation and Causal Analysis Worksheet

 

 

1.0            Purpose

 

This form should be used to document any injury, accident or emergency situation, including those that could, or have, caused a human, environmental, or property impact.  SECTION 1 is to be completed by the immediate supervisor within 24 hours of an incident.  Report incidents immediately to the ESH&Q Reporting Manager (ext. 7007) (after normal business hours: (757)876-1750), as some incidents may require immediate DOE notification.  When complete, provide a copy of this notification report to the ESH&Q Reporting Manager.

 

The remainder of the original form is to be completed and signed by the Investigation Team Leader and the responsible Division Safety Officer and the responsible Division Manager or AD, within three (3) business days of the event.  The completed, original, and signed document should then be provided to the ESH&Q Reporting Manager.

 

Brief Title of Event:

 

 

 

RESPONSIBLE DEPARTMENT/ORGANIZATION:

INCIDENT DATE/TIME:

LOCATION:

 

 

 

SUPERVISOR:

INVESTIGATION DATE:

 

 

INVESTIGATION TEAM:

 

 

 

SUMMARY OF EVENT:

 

 

 

INJURY:

INJURED EMPLOYEE NAME:

JOB TITLE:

 

 

DEPARTMENT/ORGANIZATION:

SUPERVISOR:

 

 

 

ENVIRONMENTAL IMPACT/UPSET:

TYPE OF MATERIAL:

QUANTITY:

 

 

SOURCE:

TIME FLOW WAS HALTED OR CONTAINED:

 

 

FOR INVESTIGATION TEAM (X all that apply):

 

Reportable Quantity?

 

Impact ground/soil?

 

Storm Channel/Drain?

 

Sanitary Sewer?

 

ANY CORRECTIVE ACTIONS IMMEDIATLY IMPLEMENTED: 

 

 

NOTIFICATIONS MADE - First Response Actions:

Yes

 

Date/Time

Yes

 

Date/Time

 

GUARD STATION: x4444:

 

 

ESH&Q REPORTING: x7007:

 

 

CHEMICAL ASSIST TEAM: x7863:

 

 

FIRE: (9-911)

 

 

AMBULANCE: (9-911)

 

 

OTHER:

 

 

 

CREW CHIEF (630-7050)

 

 

OTHER: 

 

 

 

Attach sketch and photographs as necessary.

SITE OBSERVATIONS:

 

 

 

WITNESS ACCOUNTS:  (Also attach narrative statement written by the injured persons.)

 

 

WEATHER CONDITIONS:

GROUND/SURFACE CONDITION:

 

 

 

OTHER INFORMATION:

 

 

 

NUMBER EACH CAUSE - Assign #1 to root cause.

CONTRIBUTING CAUSES:

 

 

WHAT PRACTICAL MEANS OF PREVENTION WERE EMPLOYED?:

 

 

Ensure all hazards are controlled and service/repair requests have been initiated if needed.

FOLLOW-UP ACTIONS TAKEN/REQUIRED:  For completed actions, list date completed and responsible manager.  For future actions, list responsible manager and estimated date of completion.  Include any needed ES&H Manual or procedural changes and enter all actions in the Corrective Action Tracking System (CATS) https://mis.jlab.org/ehs/index.php

 

 

LESSONS LEARNED:

 

 

 

INVESTIGATED BY:

DATE:

 

 

 

Distribution:

ESH&Q Reporting Manager (Original)

Division Manager or Associate Director

Associate Director ESH&Q

Division Safety Officer

ICAT Members

Department Head/Hall Leader