Incident and Injury Report Form – Nitrogen Services Compliance Management System

GENERAL INFORMATION

Report By

Report Date*

Time Zone*

Accident Date*

Time of Incident*

Superintendent*

Foreman*

Project Manager*

Project Number*

Location*

Incident

State*

County Parish*

Division

Reported To Authorities*

Yes

No

If Yes - To What Agency?*

Company Involvement *

CLASSIFICATION OF INCIDENT

Check all that apply

Treatment*

N/A

On-Site

Off-Site

Injury*

Yes

No

Illness*

Yes

No

Spill Release*

Yes

No

Fire*

Yes

No

Security Threat*

Yes

No

Property Damage*

Yes

No

Work Interruption*

Yes

No

Describe the Incident in Detail*

Attachments

Maximum file size: 516MB

Documents, pictures, drawings, etc.

INJURY INFORMATION

Do you need to enter Injury Information?*

No

Yes

Upper Body*

Upper Extremities*

Lower Extremities*

Nature of Injury or Illness*

EMPLOYEE INFORMATION

Do you need to enter Employee Information?*

No

Yes

Full Name

Telephone Number*

Marital Status

Number of Children

Occupation*

Race

Age*

Time Present Job*

Time This Industry*

Time Present Occupation*

List Witnesses and Contact Information*

MEDICAL INFORMATION

Do you need to enter Medical Information?*

No

Yes

Treatment Facility*

Date of First Treatment*

Contact Information*

INVESTIGATION

Do you need to enter Investigation details?*

No

Yes

Root Cause Analysis*

N/A

Yes

No

Type of Analysis*

N/A

Five Why

Fishbone

Other

Define Other*

Analysis Team *

Cause(s)*

Contributing Factors*

CORRECTIVE ACTIONS

Do you need to enter Corrective Actions information?*

No

Yes

Actions Already Taken*

Describe actions taken immediately upon notice of incident

Actions Still To Be Taken*

Describe actions that will be taken at a later date

Projected Date of Completing Actions*

Date of actions that have not been completed but will be completed

Person Ensuring Corrective Actions*

OFFICE USE ONLY

Completed by Safety Management

Approved By*