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NYE COUNTY INCIDENT/ACCIDENT INVESTIGATION/FACT FINDING FORM Employee name: Contact Number Supervisor name: Contact Number Department & Position: Date and Time of Accident: Location of Accident:.

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Related links form

(a) Date PIA Was Completed: August 28, 2008 American Red Cross Disaster Assistance For Foreign Nationals - 2001-2009 State Cover-June98 - US Department Of State - 2001-2009 State Electronic Passport Application Form Website 2DPPT - 2001-2009 State

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Briefly describe what happened including the sequence of events, investigate scene of incident or near miss; who was involved e.g. worker, visitor; conditions present at time of incident; what was involved, what activity (if any) was taking place prior and at time of incident.

Root Cause Analysis Steps Organize Data. Create a timeline to describe the accident. ... Identify Contributing Factors. Next, add details to the timeline, asking why each event occurred. ... Determine Root Causes. Then, ask why each contributing factor occurred.

Description of Pictures Taken: Body part injured and type of injury (be specific): If it is a Near Hit, descibe the potential injury/damage: Weather conditions at time of accident: Visibility/Lighting (ex. poor, work lights, etc.): Type and condition of floor surface (ex.

The simple model shown in Figure 1 attempts to illustrate that the causes of any incident can be grouped into five categories - task, material, environment, personnel, and management.

One common approach is called “5-Why”. This technique begins with a problem statement and then starts asking the question “Why?” Why questions are repeated a number of times (generally around 5 times, thus the name of this technique), until the root causes become more apparent.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232