FDACS-01510 Rev. 07/16 Page 2 of 4 ROOT CAUSE ANALYSIS UNSAFE ACT (PRIMARY): Failure to comply with policies/procedures; appropriate equipment/technique; Inattentiveness; Incomplete or no policies/procedures; Failure to use Inadequate/lack of JSA/standards; Inadequate training on policies/procedures; Inadequate adherence of policies/procedures; Other (specify).
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How to fill out the FL FDACS-01510 online
The FL FDACS-01510 is an essential form used for documenting incidents or accidents within the Florida Department of Agriculture and Consumer Services. This guide will provide clear, step-by-step instructions to help users complete the form online efficiently and accurately.
Follow the steps to complete the form successfully.
- Click the ‘Get Form’ button to obtain the form and open it in the editor.
- Carefully enter the accident date in the designated field, ensuring the format is correct.
- Record the reporting date, which should correlate with when you are completing the form.
- Input the full name of the employee involved in the incident, starting with the last name followed by the first name.
- Specify the job title of the employee to provide context about their role.
- In the space provided, detail how the incident or accident occurred. Use additional sheets if necessary to fully articulate the events.
- Indicate the county where the incident took place, ensuring accurate geographical identification.
- Record the county of domicile for the involved employee.
- Answer whether medical treatment was required for the employee post-incident.
- Describe the exact location where the event occurred to provide precise context.
- List the names of any witnesses who were present during the incident.
- Complete the section about the person filling out the report, including their name and signature, followed by the date of completion.
- In the management section, provide the name and position of the person completing that section of the form.
- Answer whether the person completing the report is trained in accident investigation and detail any equipment involved.
- If applicable, indicate whether a job safety analysis (JSA) exists for the equipment and the date the last JSA was performed.
- Document whether similar incidents have occurred before and whether they involved the same individual or location.
- Note if the scene was visited during the investigation, along with the date and time of the visit, if applicable.
- Complete the primary unsafe act and condition sections by selecting the relevant issues from the provided options and offering detailed explanations.
- Fill out the immediate and long-range actions to prevent recurrence, specifying any additional assistance needed.
- After finishing the form, save it with a unique filename that includes the incident date, employee name, and division or bureau name. Ensure a completed copy is kept on file and sent to the proper safety coordinator.
Take action now: Complete your FL FDACS-01510 form online!
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