ࡱ> fhcde _Ebjbjupup @J1008$`n |""""#$%HK_M_M_M_M_M_M_$6bdq_%#"#%%q_00""K`111%08""K_1%K_11YDh\"`07U&Z&7_`0`[je& eL\e\%%1%%%%%q_q_0%%%`%%%%e%%%%%%%%% :  Dept. of Administration Risk Management Division Workers Compensation Program 310 Centennial Office Bldg., 658 Cedar Street St. Paul, MN 55155 (651) 201-3000 FAX (651) 297-5471 Injured Employee s Name (Last, First, M.I.) 1.  FORMTEXT       Date of Claimed Injury (DOI) 2.  FORMTEXT       Employee Phone # 3.  FORMTEXT       Agency Name 4.  FORMTEXT       Agency Location 5.  FORMTEXT       Investigative QuestionsDescribe in detail the tasks, activities, and conditions leading up to the injury/illness.  FORMTEXT      Describe in detail how the injury/illness occurred.  FORMTEXT       Describe in detail the injury or illness.  FORMTEXT       Complete causal factor analysis on page 2 before proceeding to questions 9-12. Provide a detailed description of all hazardous conditions, such as defective equipment, excessive noise, natural, or traffic hazards that may have contributed to this injury/illness. Primary Hazard Condit Code: FORMTEXT      FORMTEXT       Provide a detailed description of all unsafe acts such as failure to use safety equipment, improper use of equipment, or unsafe posture that may have contributed to this injury/illness. Primary Unsafe Act Code: FORMTEXT      FORMTEXT       Please describe immediate corrective actions you have taken to prevent additional injuries/illnesses.  FORMTEXT       Please describe all preventative actions you are taking to reduce or eliminate similar hazards in the future.  FORMTEXT       Name, title and phone number of individual completing this form. Name  FORMTEXT       Phone  FORMTEXT       Title  FORMTEXT       Date of Investigation  FORMTEXT       Agency management review Name  FORMTEXT       Title  FORMTEXT        Incident Causal Factor Analysis Employee Name  FORMTEXT       DOI  FORMTEXT       Step 1. Review and check all hazardous conditions that may have contributed to the incident. (Circle primary hazardous condition to be used for reporting purposes and record code on line 9, page 1.) NEC-Not Elsewhere Classified UNS-Unspecified Possible Hazardous Conditions (Three digit number is for coding purposes) FORMCHECKBOX Defect, unsuitable materials 001 FORMCHECKBOX Inadequate ventilation 240 FORMCHECKBOX Uninsulated (electrical) 550 FORMCHECKBOX Defect, dull 002 FORMCHECKBOX Insufficient work space 250 FORMCHECKBOX Uncovered connections (electrical) 560 FORMCHECKBOX Defect, improper construction 003 FORMCHECKBOX Improper illumination 260 FORMCHECKBOX Unshielded (radiation) 570 FORMCHECKBOX Defect, improper design 004 FORMCHECKBOX Environmental hazard, NEC 299 FORMCHECKBOX Inadequate shield (radiation) 580 FORMCHECKBOX Defect, rough 005 FORMCHECKBOX Hazardous methods/procedure, UNC 300 FORMCHECKBOX Unlabeled/inadequate label 590 FORMCHECKBOX Defect, sharp 006 FORMCHECKBOX Inherently haz. material/equipment 310 FORMCHECKBOX Inadequate guarding, NEC 599 FORMCHECKBOX Defect, slippery 007 FORMCHECKBOX Inherently haz. method/procedure 320 FORMCHECKBOX Outside work hazard, UNS 600 FORMCHECKBOX Defect, worn, cracked, broken 008 FORMCHECKBOX Inadequate/improper tools/equipment 330 FORMCHECKBOX Defective premises 610 FORMCHECKBOX Defect, other, NEC 009 FORMCHECKBOX Inadequate help with lifting 340 FORMCHECKBOX Defective material/equipment, others 620 FORMCHECKBOX Wet, slippery, spills 020 FORMCHECKBOX Improper assignment of personnel 350 FORMCHECKBOX Other property hazard 630 FORMCHECKBOX Dress/apparel hazard, UNS 100 FORMCHECKBOX Hazardous method/procedure, NEC 399 FORMCHECKBOX Natural hazard 640 FORMCHECKBOX Lack of personal protection equipment 110 FORMCHECKBOX Placement haz., material/equipment, UNC 400 FORMCHECKBOX Public hazards, UNS 700 FORMCHECKBOX Improper/inadequate clothing 113 FORMCHECKBOX Improperly piled 410 FORMCHECKBOX Public transportation hazards 710 FORMCHECKBOX Dress/apparel hazard, NEC 119 FORMCHECKBOX Improperly placed 420 FORMCHECKBOX Traffic hazard 720 FORMCHECKBOX Environmental hazard, UNS 200 FORMCHECKBOX Inadequately secured 430 FORMCHECKBOX Other public hazard 780 FORMCHECKBOX Excessive noise 205 FORMCHECKBOX Inadequately guarded, UNC 500 FORMCHECKBOX hazard not listed 980  FORMTEXT       FORMCHECKBOX Failure to place warning signs 208 FORMCHECKBOX Unguarded 510 FORMCHECKBOX hazard not listed  FORMTEXT       FORMCHECKBOX Inadequate aisle, exits, etc. 210 FORMCHECKBOX Inadequately guarded 520 FORMCHECKBOX hazard not listed  FORMTEXT       FORMCHECKBOX Inadequate clearance 220 FORMCHECKBOX Lack of shoring 530 FORMCHECKBOX hazard not listed  FORMTEXT       FORMCHECKBOX Inadequate traffic control 230 FORMCHECKBOX Ungrounded (electrical) 540 FORMCHECKBOX hazard not listed  FORMTEXT      Step 2. Review and check all unsafe acts that may have contributed to the incident. (Circle primary unsafe act to be used for reporting purposes and record code on line 10, page 1.) Possible Unsafe Act(Three digit number is for coding purposes) FORMCHECKBOX Caulking, packing under pressure 051 FORMCHECKBOX Use of hand instead of tool 356 FORMCHECKBOX Exposure to moving material 558 FORMCHECKBOX Clean, oil, adjust moving equipment 052 FORMCHECKBOX Improper use of equipment, NEC 359 FORMCHECKBOX Unsafe posture/position, NEC 559 FORMCHECKBOX Weld, repair without clearance 056 FORMCHECKBOX Inattention to footing/surroundings 400 FORMCHECKBOX Driving errors, public road, UNS 600 FORMCHECKBOX Work on energized equipment 057 FORMCHECKBOX Make safety device inoperative 450 FORMCHECKBOX Too fast/slow 601 FORMCHECKBOX Unsupervised actions, NEC 059 FORMCHECKBOX Block, plug, tie safety device 452 FORMCHECKBOX Enter/leave on vehicle traffic side 602 FORMCHECKBOX No personal protection equipment used 100 FORMCHECKBOX Disconnect/remove safety device 453 FORMCHECKBOX Failure to signal turn, stop, backup 603 FORMCHECKBOX Unsafe personal attire 150 FORMCHECKBOX Misadjust safety device 454 FORMCHECKBOX Failure to yield right-of-way 604 FORMCHECKBOX Failure to secure/warn, UNC 200 FORMCHECKBOX Improper replacement of device 456 FORMCHECKBOX Following to closely 606 FORMCHECKBOX Fail to lock/block 201 FORMCHECKBOX Inoperative safety device, NEC 459 FORMCHECKBOX Improper passing 607 FORMCHECKBOX Fail to shut off equipment 202 FORMCHECKBOX Working at unsafe speed, UNC 500 FORMCHECKBOX Turn from wrong lane 608 FORMCHECKBOX Fail to place warning signs 203 FORMCHECKBOX Feed/supply to rapidly 502 FORMCHECKBOX Driving errors, public road, NEC 609 FORMCHECKBOX Start/stop equipment without warning 207 FORMCHECKBOX Jump from elevation 503 FORMCHECKBOX Unsafe placing, mix, combine, UNC 650 FORMCHECKBOX Fail to warn, NEC 209 FORMCHECKBOX Operate vehicle unsafe speed 505 FORMCHECKBOX Combining resulting in fire/exp. 653 FORMCHECKBOX Horseplay 250 FORMCHECKBOX Running 506 FORMCHECKBOX Unsafe placing of vehicle/equipment 655 FORMCHECKBOX Improper use of equipment, UNC 300 FORMCHECKBOX Throwing materials 508 FORMCHECKBOX Unsafe placement of tools, scrap 657 FORMCHECKBOX Equipment use improper manner 301 FORMCHECKBOX Unsafe speed, NEC 509 FORMCHECKBOX Unsafe placement, NEC 659 FORMCHECKBOX Overloading equipment 305 FORMCHECKBOX Unsafe posture/position, UNC 550 FORMCHECKBOX Use of unsafe equipment, UNS 750 FORMCHECKBOX Improper use of equipment, NEC 309 FORMCHECKBOX Confined space violations 552 FORMCHECKBOX Unsafe act not listed 900  FORMTEXT       FORMCHECKBOX Improper use of body parts, UNC 350 FORMCHECKBOX Ride in unsafe position 555 FORMCHECKBOX Unsafe act not listed  FORMTEXT       FORMCHECKBOX Insecure grip 353 FORMCHECKBOX Exposure to suspended load 556 FORMCHECKBOX Unsafe act not listed  FORMTEXT       FORMCHECKBOX Improper hold of object 355 FORMCHECKBOX Exposure to swinging load 557 FORMCHECKBOX Unsafe act not listed  FORMTEXT      Step 3. Check all other contributing factors that may have contributed to the incident. Other Contributing Factors FORMCHECKBOX Lack of policy/procedures FORMCHECKBOX Insufficient sup training FORMCHECKBOX Inadeq workplace inspect FORMCHECKBOX Safety rules not enforced FORMCHECKBOX Improper maintenance FORMCHECKBOX Inadequate equipment FORMCHECKBOX Hazards not identified FORMCHECKBOX Inadequate supervision FORMCHECKBOX Unsafe design/construction FORMCHECKBOX PPE unavailable FORMCHECKBOX Inadequate job planning FORMCHECKBOX Unrealistic schedule FORMCHECKBOX Insufficient ee training FORMCHECKBOX Inadequate hiring  FORMCHECKBOX Poor process designStep 4. Based on information above, consider possible corrective actions or measures to control immediate hazard. 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",.ߓ{yaSh(CJOJQJ^JaJ/jhX[hX[CJOJQJU^JaJU/jhX[hX[CJOJQJU^JaJ/jhX[hX[CJOJQJU^JaJhHCJOJQJ^JaJhHCJOJQJ^JaJ/jhX[hX[CJOJQJU^JaJh#uCJOJQJ^JaJ#jh#uCJOJQJU^JaJ FORMCHECKBOX Other  FORMTEXT      Step 5. Based on information above, consider possible preventative actions to eliminate or permanently control hazards so injuries do not reoccur. Preventative Actions FORMCHECKBOX Fix or repair FORMCHECKBOX Warning signs FORMCHECKBOX Install protective barriers FORMCHECKBOX Employee communication FORMCHECKBOX Utilize safety equipment FORMCHECKBOX Conduct inspections FORMCHECKBOX Institute safety procedures FORMCHECKBOX Safety training FORMCHECKBOX Other  FORMTEXT       FORMCHECKBOX Modify process/procedures FORMCHECKBOX Engineering controls FORMCHECKBOX Other  FORMTEXT      Step 6. Complete questions 9-12 on page 1. Multiple corrective and preventative actions may be necessary to ensure control of the hazard(s) and to prevent future injuries. Reporting Information This form is to be completed by the employees immediate supervisor, the agencys investigator, or designee and submitted in conjunction with the First Report of Injury. Complete this form in its entirety. The Agency Claims Investigation form will assist your agency in identifying the causal factors of workplace injuries/illnesses and the implementation of corrective actions while also helping the Department of Administration Workers Compensation Program in determining the compensability of the reported work-related injury or illness and in identifying possible subrogation sources. Please type or print legibly. If you need additional space when responding to any of the questions, you may add additional pages.  Form InstructionsItems 1 through 5 Same information as reported in the First Report of Injury form. Item 6 Describe in detail the task the employee was performing that lead to the injury/illness. This will assist you in identifying the causal factors of the injury/illness. Item 7 Based on your investigation, how did the injury/illness occur? Your description should include details of the circumstances and events that caused the injury/illness. Item 8 Describe in detail the employees injury or illness. Your description should include all body parts (i.e., neck, cheek bone, left toe) affected and the extent of injury or illness (i.e., congestion, laceration, puncture or combination thereof). Items 9 through 12 Describe action(s) taken or to be taken to prevent this occurrence from happening again. See page 2, Incident Causal Factor Analysis, to complete these questions. Item 13 Name, title and phone number of the person conducting the investigation of the employees claimed injury or illness and the date of the investigation. Item 14 The completed investigation should be reviewed and signed by agency management (such as the area, program, divisional manager of the employee injured). 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A copy of this form can be retained in the agencys workers compensation file.      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