"Incident/Accident Analysis Form" - Montana

Incident/Accident Analysis Form is a legal document that was released by the Montana Department of Corrections - a government authority operating within Montana.

Form Details:

  • The latest edition currently provided by the Montana Department of Corrections;
  • Ready to use and print;
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  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Montana Department of Corrections.

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INCIDENT/ACCIDENT ANALYSIS FORM
Accident #
Employee Information:
Areas of Concern
Employee Injury Results
Employee Name:________________________________
Has the worker sought medical attention: Y / N Date:_____________
Slips/Trips/Falls
Location:_______________________________________
What parts of the body were injured:____________________________
Lifting / Overexertion
Date of Injury:______________
Time:______________
___________________________________________________________
Gate issues
Date Reported to Supervisor:_____________________
___________________________________________________________
Bloodborne Pathogen ex.
Dept:__________________________________________
___________________________________________________________
Restraint Issues
Claims Cost Control - Have all parts of faulty equipment, machinery
Occupation of employee:_________________________
Chemical Exposures
or other evidence associated with this accident been preserved?
Car accidents / transport
_____YES _____NO - Explain___________________________________
Falling objects
__________________________________________________
Repetative Motion
__________________________________________________
Struck by Object
Description
1. Describe the incident/accident. Include the machine, object or substance involved and explain exactly what the injured worker was doing._______________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
2. What did each co-worker or witness say about the incident/accident? (If necessary, attach additional sheets).______________________________________________
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
3. If pain gradually occurred, how does the employee relate the problem to work?________________________________________________________________
_____________________________________________________________________________________________________________________________________
4. Have other employees had injuries, accidents or near misses at or near this job site? If so, when, where and how are they related to this incident/accident?__________
_____________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
5. If an unsafe act(s) was a cause of this incident/accident, why was the unsafe act committed?_____________________________________________________________
_____________________________________________________________________________________________________________________________________
6. If an unsafe condition(s) was a cause of the incident/accident, why did the condition exist?_____________________________________________________________
_____________________________________________________________________________________________________________________________________
7. If an organization cause(s) was a cause of the incident/accident, why did the cause exist?________________________________________________________________
____________________________________________________________________________________________________________________________________
cc: Reviewing Manager
Signature of person filling out the form:___________________________
Date:__________
Safety Committee
Signature of Supervisor____________:___________________________
Date:__________
INCIDENT/ACCIDENT ANALYSIS FORM
Accident #
Employee Information:
Areas of Concern
Employee Injury Results
Employee Name:________________________________
Has the worker sought medical attention: Y / N Date:_____________
Slips/Trips/Falls
Location:_______________________________________
What parts of the body were injured:____________________________
Lifting / Overexertion
Date of Injury:______________
Time:______________
___________________________________________________________
Gate issues
Date Reported to Supervisor:_____________________
___________________________________________________________
Bloodborne Pathogen ex.
Dept:__________________________________________
___________________________________________________________
Restraint Issues
Claims Cost Control - Have all parts of faulty equipment, machinery
Occupation of employee:_________________________
Chemical Exposures
or other evidence associated with this accident been preserved?
Car accidents / transport
_____YES _____NO - Explain___________________________________
Falling objects
__________________________________________________
Repetative Motion
__________________________________________________
Struck by Object
Description
1. Describe the incident/accident. Include the machine, object or substance involved and explain exactly what the injured worker was doing._______________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
2. What did each co-worker or witness say about the incident/accident? (If necessary, attach additional sheets).______________________________________________
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
3. If pain gradually occurred, how does the employee relate the problem to work?________________________________________________________________
_____________________________________________________________________________________________________________________________________
4. Have other employees had injuries, accidents or near misses at or near this job site? If so, when, where and how are they related to this incident/accident?__________
_____________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
5. If an unsafe act(s) was a cause of this incident/accident, why was the unsafe act committed?_____________________________________________________________
_____________________________________________________________________________________________________________________________________
6. If an unsafe condition(s) was a cause of the incident/accident, why did the condition exist?_____________________________________________________________
_____________________________________________________________________________________________________________________________________
7. If an organization cause(s) was a cause of the incident/accident, why did the cause exist?________________________________________________________________
____________________________________________________________________________________________________________________________________
cc: Reviewing Manager
Signature of person filling out the form:___________________________
Date:__________
Safety Committee
Signature of Supervisor____________:___________________________
Date:__________