Pipe Pros Supervisor's Accident Investigation Report Get all the facts - WHO, WHAT, WHERE, WHEN, WHY, HOW - Study the Accident Site. NOTE: All accidents, including first aid cases, shall be investigated and reported on this form and sent to the Corpus office within 24 hours to be reviewed to aid in accident/loss control and accident/incident prevention. All spaces are to be completed to the best of your ability. Region*Select your locationCorpus ChristiMidlandKilgoreLafayetteNATURE OF ACCIDENT (Check all that apply) First Aid Treatment Medical Treatment Hospitalization Fatality Equipment Damage Other (explain) OtherPERSONAL INFORMATIONName of Injured* First Last SSN*English Speaking?*YesNoWhat Language?Name of Injured First Last Experience Factor:ACCIDENT INFORMATIONExact location of injury: (example: Rig No., Job Site)Exact worksite location of injury; example: Stairs, Floor No.)Physical address where accident occurred: Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code SupervisorContact name at accident site: First Last Contact phone number at accident site:Injury Date: Date Format: MM slash DD slash YYYY Injury Time: : HH MM AM PM Injury Occurred:On the JobOff the JobDate Accident Reported: Date Format: MM slash DD slash YYYY Time Accident Reported: : HH MM AM PM Date Accident Investigated: Date Format: MM slash DD slash YYYY Time Accident Investigated: : HH MM AM PM Was the employee doing his regular job?YesNoWas the employee offered medical treatment?YesNoName of Medical FacilityAddress of Medical Facility Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name of Doctor First Last Did the employee require medical services or treatment?YesNoDrug Screen Requested?YesNoDrug Screen Taken?YesNoWitnesses:What was the nature of the employee’s injury? (Check all that apply) Abrasion Cut Drowning Heat Exhaustion Insect Sting Poisoning Strained Amputation Stitched Electrocution Hernia Irritation Puncture Burn Contusion (bruise) Foreign Body Illness Jammed Smashed/Crushed Concussion Dislocation Fracture Infection Pain Sprained Other ( explain) OtherWhat part of the employee’s body was injured? (Check all that apply) Abdomen Chest Internal Ankle (left) Ankle (right) Eye (left) Eye (right) Hip (left) Hip (right) Thigh (left) Thigh (right) Back Face Mouth Arm (left) Arm (right) Finger(s) Knee (left) Knee (right) Body Head Neck Ear (left) Ear (right) Foot (left) Foot (right) Leg (left) Leg (right) Toe(s) Buttock Groin Elbow (left) Elbow (right) Hand (left) Hand (right) Shoulder (left) Shoulder (right) Wrist (left) Wrist (right) Other (explain) OtherWill accident result in lost time?YesNoUnknownLight duty available?YesNoAdditional Comments:ACCIDENT ANALYSIS (Describe in detail where applicable)Type of Accident: (check all that apply) Caught in or Under Exposure to Hot l Cold Exposure to Radiation Illness Insect Sting/Bite Slip/Trip Chemical Exposure Exposure to Noise Fall-Same Level/Different Level Improper Movement Position Motor Vehicle Accident Struck By/Against Other (explain) OtherDescribe how injury/accident occurred:Cause of Accident: (check all that apply)Unsafe Conditions Hazardous Arrangement Improper Lighting Improper Ventilation Defective Tool/Equipment Defective Missing Guard Improper Dress/Protective Clothing Noise Hazard Poor Housekeeping Weather Conditions Inadequate Warning/Training Lack of Wrong Procedures Wrong Tool/Equipment Other (explain) OtherReason Conditions Existed Economics/Cost Related Defect Caused by Normal Use Defect caused by Misuse/ Abuse Caused by Employee-Injured/Other Design/Construction of Tool/Equipment Proper Equipment/Tools Unavailable Other(explain) OtherUnsafe Conditions Failure to Warn Horseplay Procedure Deviation Unsafe Position Making Safety Devices Not Using Protective Equipment Operating Without Authority Unsafe Use/Misuse or Tools/Equipment Use of Defective Tools/Equipment Operating at Unsafe Speed Other(explain) OtherReason Unsafe Action Committed Fatigue Inattention Physical Limitations Unaware of Hazard Unaware of Safe Method Tried to Avoid Extra Effort Tried to Gain or Save Time Defect Caused by Misuse/ Abuse Improper/Disregard of Training Procedures Proper Tools/Equipment Unavailable Other(explain) OtherDescribe why injury/accident occurred:Did an employee of another company cause the accident?YesNoIf yes, name employee and company:Was the accident caused by a tool or equipment?YesNoBelonging to another company?YesNoIf yes, list tool/equipment name, manufacturer and company:Additional Comments:What should be done to prevent these types of accidents in the future?Investigated by: First Last Completed and Sent by: First Last Date Date Format: MM slash DD slash YYYY