Flash Injury/ Near Miss Reporting Incident Report Initial Flash ReportThis report contains confidential information for internal use only. If it includes health-related details, it may be subject to HIPAA regulations. Unauthorized disclosure or sharing is strictly prohibited and may result in disciplinary or legal action. Please record as much as you can on this Flash Report. This report will immediately notify KRB management of the incident. AWLYour Name(Required)Your Phone(Required) Your EmailName of person if applicable or describe property damageIncident InvolvedPlease note the Date of the incident. Date of Incident(Required)MM slash DD slash YYYY This field is hidden when viewing the formTime of IncidentPlease note the Time of the incident. Hours : Minutes AM PM AM/PM Enter the Time the incident occurred.Time of the Incident(Required)Incident Type(Required) Injury/ Illness Near Miss Environmental FatalityImmediate Response Called First Responders to the area Injured transported to urgent care/hospital/professional facility No care needed Spill clean up Equipment taken out of service Corrective maintenance Drug/ Alcohol Testing ConductedBreakroomBuilding 1Building 2Building 3Building 4Building 5Building 6Off SiteOffice BuildingParking LotWhere did the incident occur?(Required)Briefly explain what happened. Include what the injured was doing prior to the incident, and what tools or equipment were in use at the time of the incident. Describe the Incident.(Required)“Tom was changing the tooling on his CNC without gloves when the tool slipped and cut his fingers.”Describe the injury or property damage to the best of your knowledge.Describe the injury or damage.(Required)“Tom had a deep cut on all 4 fingers along the inside of his hand and his palm.”WitnessesPlease name anyone who was in the area of the incident and may be able to provide additional information. Use the + to add names to the list. Add RemovePlease note anything you feel important that hasn’t been covered above.Additional ThoughtsInvestigation Check when proceeding with the investigation.Lead Investigator Date of InvestigationMM slash DD slash YYYY Investigation Team Members Add RemoveLost Time Yes NoRecordable Injury Yes NoAdditional Witness Identified Add RemoveMedical Attention Details Was a Medical Professional consulted regarding this incident? Date of VisitMM slash DD slash YYYY Medical Professional NameContact InfoSafeStart StoryUsing your SafeStart trainng, please complete the following questions as throughly as possible.SafeStart State ObservationWhat is your observation of the cause of the injury at the time of the incident. Rushing Frustration Fatigue ComplacencySafeStart Errors ObservationWhat is your observation of the errors that occurred resulting in the incident. Eyes not on Task Mind not on Task Line of Fire Balance, Traction, GripAdditional details determined during the investigationWhat could have been done to prevent this injury/ incident?Action PlanPlease record the action plan tasks with a description of task, due date and who the task was assigned. You may add as many action items as necessary.Action Plan Task DescriptionExpected Completion DateAssigned To Add RemoveWhat changes do you suggest to prevent this incident from recurring? Stop this Activity Guard the Hazard Training – Employees Training – Supervisor Redesign Task Steps Redesign Workstation Write New Policy Enforce Existing Policy Routinely Inspect for the Hazard Personal Protective EquipmentIf this report is for property damage, please estimate the value of the damage.Damage ValueAttachmentsPlease upload any pictures or documents detailing the incident. Also include files that include witness statements, etc. Drop files here or Select files Max. file size: 10 MB, Max. files: 5.
