2. City of Burlington Accident/Injury Reporting Procedures

3. Accident/Injury Reporting  If trained to do so, provide 1 st Aid as needed.  Secure the scene or Lockout involved equipment.  Notify Occupational Health of any injuries and escort injured employee(s) as directed @ 516-6593 or 229-3584.  Notify Supervision of the incident and provide brief description of who, what, when, & where.  If injuries are severe notify Director of Safety @ 516-7456. When an injury or incident occurs while on the job what needs to happen? These first steps should occur within the first few minutes

4. Accident/Injury Reporting  Once the injured employee(s) has been treated, it is important for he/she to discuss the circumstances that lead to the incident. (While this interview does not have to happen immediately, a more accurate account will be expressed if performed as soon as possible after the incident)  Supervisor documents facts on the Supervisor’s Incident Investigation Report  Injured employee documents the facts on the Employee Statement of Accident/Incident Report When an injury or incident occurs while on the job what needs to happen? These next steps should occur soon after treatment

5. Accident/Injury Reporting  Both the employee and supervisor should break apart NCR form and route copies by color designation  For OSHA Recordability purposes, both the Employee and Supervisor Form must be completed and distributed under all circumstances within 1-2 working days. (CLOCK IS TICKING) When an injury or incident occurs while on the job what needs to happen? These final steps should occur after completing forms

6. Accident/Injury Reporting Why is it important to Document all work related incidents?  In the event of an injury, illness or fatality it’s the law. Under 29 CFR 1904 employers are required to maintain an updated log of both OSHA recordables and 1 st aid incidents.  Without proper & timely documentation, your Worker’s Compensation case may not be able to proceed and could even be denied.  If no investigation is performed, no attempts at corrective action is documented, nor can the case be used to prevent future occurrences.

7. Accident/Injury Reporting Why do accidents hurt more than once? Other than the obvious initial pain and suffering that occurs from an injury or illness, the Employee, Supervisor, Department Head and ultimately the City of Burlington have to deal with the loss or partial loss in the following ways: EMPLOYEE -- Time to heal/ +pain -- Loss of wages -- Impairment (Temp/Perm) SUPERVISOR -- Loss of talent/workforce -- Decreased productivity -- Jobs may go undone -- Increased stress DEPT. HEAD -- Loss of talent -- Decreased productivity -- Jobs may go undone -- Increased stress -- Decreased morale -- Increased workload -- Cost of replacement -- Cost of repairs CITY -- Workers Compensation cost -- Cost to train or re-hire -- Decreased morale -- Cost of repairs -- Image

8. Accident/Injury Reporting City of Burlington Employee’s Statement and Supervisor’s Incident Investigation Report Forms  Employee’s Statement  Supervisor’s Incident Investigation Report BOTH ARE REQUIRED TO BE COMPLETED

9. So What Do These COB Accident/Incident Forms Look Like…

10. CITY OF BURLINGTON EMPLOYEE’S STATEMENT ACCIDENT/INCIDENT REPORT To be Completed by employee – Please PRINT and Answer All Questions Completely (Please Complete For Near Hits Also) To be Completed by Employee Name: _________________________________________________________________ Department: ________________________ Job Title: _________________________________ Home Address: __________________________________________________________________ Telephone Number: Work ( ) ___________________________ Home ( ) ____________________________ Did injury occur at work: ____ Yes ____ No How did injury/illness occur? Suddenly_______ Gradually_______ Date and Time of Injury/Illness: _____________________ Hours of Normal Work Shift: ____________ Name of Supervisor: _________________________________ Location where injury Occurred: ___________________________ When did you notify your supervisor: Date: ______________________ Time: __________________________ Names of witnesses: ____________________________________________________________ What part(s) of your body was/were affected by this injury or illness?____________________________________ Nature of injury (bruise, strain, cut, broken bone, etc): _______________________________________________ What caused the injury/illness and how did it happen Please be specific:__________________________________________________________ ___________________________________________________________________________________________________________________ (Please Use additional paper if necessary) Treatment required: ____ First Aid ____ Medical Treatment ____ Fatality ____ OSHA recordable What specific body part(s) were injured: ________________________________________________ Nature of Injury (Bruise, Cut, Strain, Rash, etc.): ___________________________________________ Did injury result in more than one day of work missed not including day of accident? _____ Yes _____ No Was supervision notified immediately? _____ Yes _____ No If no, When: ______________________ Did you go to the COB Occupational Health Clinic for Treatment? ____ Yes ____ No If no, please explain. ______________________________________________________________________ Signature of Injured EmployeeDate ______________________________________________________________________ Signature of WitnessDate Copy Distribution White—City NurseCanary –Safety DirectorPink—SupervisorGold--Department Head

11. City of Burlington Supervisor’s Incident Investigation Report (FORM TO BE USED TO DOCUMENT NEAR HITS ALSO) To be Completed by Supervisor Injured Employee’s Name: ____________________ Your Name: _______________________ Have you reviewed the Employee’s Written Notice to Supervisor? (Page One) Yes No Did the injury result in more than one day away from work not including day of incident? Yes No Did the employee’s injury/illness result in any restricted work days? Yes No NATURE OF INJURYTYPES OF ACCIDENTSPART OF BODY AFFECTED  Amputation  Burn/Scald  Contusion/Bruise  Cut/Puncture  Rash from plants  Electric Shock/Burn  Inhalation -Toxic Substance  Freezing/frostbite  Hearing Loss/Impairment  Heat Exhaustion/Sunstroke  Hernia/rupture  Scratches, Abrasions  Sprains/Strains  Fracture  Multiple Injuries  Insect Bite/Sting  Needle Puncture  Other  Struck against Object  Struck by Flying Object  Struck by Other Objects/Person  Falls (Same Level)  Fall (elevated)  Caught in/under or between  Rubbed or Abraided by Object  Bodily Reactions (Over Exertion)  Contact w/ Temp. Extremes  Exposure to Electricity  Toxic material Exposure  Noise Exposure  Disease Exposure  Repetitive Motion  Vehicle or Equipment Accident  Other  Head  Eyes  Arms (above wrist)  Hand  Fingers  Upper Extremity, multiple parts  Abdomen, also Internal Organs  Back  Chest, also Internal Organs  Shoulder(s)  Trunk, multiple parts  Legs (above ankle)  Foot  Toes  Lower Extremity, Multiple parts  Multiple Parts of Body (Severe)  Digestive System  Respiratory System  Circulatory System  Skin  Other Check the appropriate boxes below: Was the injured employee observing City of Burlington Safe Work Practices including the wearing adequate Personal Protective Equipment as required to perform the job safely? Yes No IMMEDIATE CAUSE(S)Explain:  Equipment  Environment  Hazardous conditions  Personnel  Mgt.  Unsafe Act BASIC CAUSE & CONTRIBUTING FACTOR(S)Explain:  Environmental conditions  Hazardous conditions  Lack of safety instruction/training  Personnel  Mgt. CORRECTIVE ACTION I have taken the following immediate actions to reduce recurrence:  Temporary  Permanent Explain: I recommend the following action(s) to prevent recurrence and anticipant completion by: / /Signature Department Heads Comments:

12. Accident/Injury Reporting  Your Supervisor  Department Head  Your Departmental Representative on the Central Safety Committee  Occupational Health Clinic  Director of Safety Where Can You Find These Forms?

13. Accident/Injury Reporting Should you have any questions regarding this course or need help in completing these forms please contact the COB Director of Safety @ 513-5463. For occupational injuries and illnesses please contact the COB Occupational Health Clinic @ 229-3584. Should an injury occur after hours (8-5), please contact the Occupational Health Nurse immediately @ 516-6593 for instructions.