Air | LifeShare

Accident Investigation Report

Accident Report Log Number

QA Safety Database #

Report Status*

OSHA Recordable Injury (ORI)

Yes

Select if recordable injury.

Date Incident Reported*

Not the date of the accident but the date the accident was reported.

Time Employee Started Work*

:

Incident Center*

Incident Department*

Date of Incident*

The date the employee had the incident.

Time of Incident*

:

The time the employee had the incident.

Employee Information

Employee Name*

First Last

SSN*

Collection of the SSN is required in order to positively identify the employee and correlate documentation related to claims pursued by employee.

Date of Birth*

Sex*

Driver's License #

DL# State

Speaks English*

Yes

No

If "No", Language

The language you most often speak.

Center*

Department*

Hire Date*

Company Experience Years

Years employed.

Company Experience Months

Months employed.

Supervisor*

First Last

Supervisor Phone*

Employee Address

Street Address Address Line 2

The physical address of where the employee lives.

City*

State*

Zip*

Parish/County*

Phone*

Incident Details

Did employee die?

Yes

Select if death occurred.

Date of Death*

Location Name of Incident*

Name of place where the incident occurred.

Location of Incident*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parish/County*

Category*

Event Type*

Weather*

Lighting*

Area at Location of Incident*

Ex: Donor collections area.

Activity at Time of Incident*

Function Performed by Employee*

BUN Number

Equipment Type

Equipment Number

Nature of Injury

Underlying Cause

Left - Body Part(s) Injured*

Allows multi-select.

Right - Body Part(s) Injured*

Allows multi-select.

Brief Description*

Did employee receive treatment?

Yes

Select if treatment was administered.

Did employee refuse treatment?

Yes

Select if treatment was administered.

Signature*

Date*

Treatment Information

Where did employee receive treatment?*

Select all that apply.

Hospital/Facility Name*

Hospital/Facility Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Doctor/Medical Attendee*

Hospital/Facility Phone*

Accident Investigation Report

Company Vehicle Involved?

Yes

Select if company vehicle is involved.

Company Vehicle Information

Unit Number*

Make*

Model*

Year*

Color*

License Plate*

State*

Damage Location*

Allows multi-select.

Description of Damage*

Damage Estimate Over $5,000?

Yes

Select if damage over $5,000.

Vehicle Towed

Yes

Select if vehicle was towed.

Team Member and/or Witness Information

Do you have any team member(s) and/or witness information to add?

Yes

Select if yes.

Do you have Team Member(s) information to add?

Yes

Select if yes.

Please Add Team Member Details Below

Name*

First Last

Title*

Phone*

Upload Statement

Max. file size: 512 MB.

Name

First Last

Title

Phone

Upload Statement

Max. file size: 512 MB.

Name

First Last

Title

Phone

Upload Statement

Max. file size: 512 MB.

Name

First Last

Title

Phone

Upload Statement

Max. file size: 512 MB.

This field is hidden when viewing the form

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Do you have Witness information to add?

Yes

Select if yes.

Please Add Witness Details Below

Name*

First Last

Phone*

Upload Statement

Max. file size: 512 MB.

Name

First Last

Phone

Upload Statement

Max. file size: 512 MB.

Name

First Last

Phone

Upload Statement

Max. file size: 512 MB.

Name

First Last

Phone

Upload Statement

Max. file size: 512 MB.

Accident Investigation Report

Is there any damage that occurred to non-company property and/or bodily injury to a person not employed by LifeShare Blood Center?

Yes

Select if yes.

Non-Company Information

Is there non-company owned vehicle damage?

Yes

Select if yes.

Enter Non-Company Owned Vehicle Information Below

Make*

Model*

Color*

Year*

License Plate*

State*

Damage Location*

Allows multi-select.

Damage Description*

Owner Name*

First Last

Owner Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Owner Phone*

Owner Vehicle Insurance Company

Policy Number

Insurance Company Phone

This field is hidden when viewing the form

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Is there non-company owned propery damage?

Yes

Select if yes.

Enter Non-Company Owned Property Information Below

Property Type*

Property Description*

Contact Name*

First Last

Address of Property*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Phone*

Additional Phone

Insurance Company

Policy Number

Phone

This field is hidden when viewing the form

Section Break

Is there bodily injury to any person not employed by LifeShare Blood Center?

Yes

Select if yes.

Enter Bodily Injury Details Below

Did death occur?

Yes

Select if yes.

Date*

Injured Name*

First Last

Injured Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Injured Phone*

Additional Phone

Left - Body Part(s) Injured*

Allows multi-select.

Right - Body Part(s) Injured*

Allows multi-select.

Brief Description of Injuries*

Insurance Company

Policy Number

Insurance Company Phone

Accident Investigation Report

Any interaction with law enforcement to enter?

Yes

Police citations, police reports, etc.

Enter Law Enforcement Information Below

Accident Report Issued?

Yes

Select if yes.

Officer/Deputy Name*

First Last

Agency*

Citation Issued?

Yes

Select if yes.

Name Citation Issued To*

First Last

Reason for Citation*

Accident Investigation Report Completed By

Name*

First Last

Title*

Phone*

Post-Accident Drug Test Administered?

Yes

Select if yes.

Type*

DOT

Non-DOT

Post-Accident Alcohol Test Administered?

Yes

Select if yes.

Type*

DOT

Non-DOT

If a post-accidental test is not administered, explain why.*

Chronological Sequence of Events

Sequence*

Event Description

Sequence

Event Description

Sequence

Event Description

Sequence

Event Description

Sequence

Event Description

Root Cause

Root Cause Description*

Physical Factors

Human Factors

Operating Systems

Other Factors

Committee Members

Chairperson*

First Last

Title*

Committee Member Name

First Last

Title

Committee Member Name

First Last

Title

Committee Member Name

First Last

Title

Committee Member Name

First Last

Title

Recommendations

Rec. Number*

Title*

Due Date*

Date Completed

Recommendation Details*

Responsible Employee*

First Last

Employee(s) responsible for implementing recommendation.

Responsible Employee

First Last

Responsible Employee

First Last

Rec. Number

Title

Due Date

Date Completed

Recommendation Details

Responsible Employee

First Last

Responsible Employee

First Last

Responsible Employee

First Last

Rec. Number

Title

Due Date

Date Completed

Recommendation Details

Responsible Employee

First Last

Responsible Employee

First Last

Responsible Employee

First Last

Accident Investigation Report

Signatures

Department Coordinator*

First Last

Reviewed Recommendations?*

Yes

Signature*

Safety Officer*

First Last

Reviewed Recommendations?*

Yes

Signature*

Executive Director/Designee*

First Last

Reviewed Recommendations?*

Yes

Signature*

Risk Manager*

First Last

Reviewed Recommendations?*

Yes

Signature*

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N/A
Ankle
Arm
Back
Elbow
Eye
Finger - Thumb
Finger - Index
Finger - Middle
Finger - Ring
Finger - Small
Foot/Heal
Forearm
Hand
Head/Face
Knee
Leg - Upper and Lower
Neck
Ribs
Shoulder
Whole Body
Wrist
Big Toe
2nd Toe
3rd Toe
4th Toe
5th Toe
Other
Multiple

N/A
Ankle
Arm
Back
Elbow
Eye
Finger - Thumb
Finger - Index
Finger - Middle
Finger - Ring
Finger - Small
Foot/Heal
Forearm
Hand
Head/Face
Knee
Leg - Upper and Lower
Neck
Ribs
Shoulder
Whole Body
Wrist
Big Toe
2nd Toe
3rd Toe
4th Toe
5th Toe
Other
Multiple

LifeShare A.I.R

Accident Investigation Report

Employee Information

Incident Details

Treatment Information

Accident Investigation Report

Company Vehicle Information

Team Member and/or Witness Information

Please Add Team Member Details Below

Section Break

Please Add Witness Details Below

Accident Investigation Report

Non-Company Information

Enter Non-Company Owned Vehicle Information Below

Section Break

Enter Non-Company Owned Property Information Below

Section Break

Enter Bodily Injury Details Below

Accident Investigation Report

Enter Law Enforcement Information Below

Accident Investigation Report Completed By

Chronological Sequence of Events

Root Cause

Committee Members

Recommendations

Accident Investigation Report

Signatures