INJURY AND ILLNESS INVESTIGATION FORM KEY Section in Austin Orange, underlined – appears as title. Information/Examples Blue text Special/Important Notes Highlighted – black text To be filled out/completed by AM Normal black text Notes to remember when completing an investigation: The primary aims of all incident investigations and reports is to identify and answer: Who was injured? What happened? When did it happen? Where did it happen? Why it happened? As well, investigations should also identify: How will we prevent recurrence/fix it? Was product involved (include the product size, weight, ASIN)? Include photos and/or video footage to the report Always be as specific (and accurate) as possible (and is necessary) in details; particularly about details relating to: what the AA was doing when they reported they were injured; where they reported the incident occurred; when they reported the incident & to whom; and, what was found during the investigation. Not every case will need the same level of detail. Adjust the detail and time of the investigation according to: the actual injury, and what could have happened. E.g. if someone received a ‘paper cut’ from a box because they weren’t wearing their gloves, the solution is relatively simple. However, where someone reports a sore foot because they dropped a fitness weight, more detail is required to fully identify the details (because the outcome is possibly going to be much worse than a small paper cut). Page 1 of 10 INJURY AND ILLNESS INVESTIGATION FORM INSTRUCTIONS: Complete the form and send to OM, OMR, & Safety Specialist via SLACK group for review. Save form in accordance with filename convention FILE TYPE – LOGIN - DATE. NOTE: The OMR will create the initial case in Austin and send the link to the AM completeing the investigation/report. If no OMR or safety personnel are on site, then the AM will be expected to initiate the case and complete the investigation/report. Initial Information Date of incident: Click or tap to enter a date. Date reported: Click or tap to enter a date. Alias of employee (login): Employee occupation: Choose an item. Shift Start Time: 00:00 AM ☐ PM ☐ Side of Body: Choose an item. Detailed Body Part: Choose an item. Location at time of injury: Choose an item. Time of incident: 00:00 AM ☐ PM ☐ Time reported: 00:00 AM ☐ PM ☐ Alias of manager or supervisor: Shift: Choose an item. Other (Shift code) Type: Choose an item. Principal Body Part: Choose an item. Symptom for body part: Choose an item. Did this incident occur on the road (OTR)?: DESCRIPTION (To view an example description CTRL click HERE or scroll to the end of this template!): AA’s Account of incident – (Automatically inputted in Austin from Initial Report) AM’s Account of incident - TYPE OF IMPACT – PRIMARY Choose an item. TYPE OF IMPACT – SECONDARY Choose an item. Page 2 of 10 INJURY AND ILLNESS INVESTIGATION FORM DID THIS INCIDENT OCCUR DURING OVERTIME? YES ☐ NO ☐ DID THE INCIDENT OCCUR DURING LABOR SHARE? YES ☐ NO ☐ DID THE INJURY OCCUR OUTSIDE OF WORK? YES ☐ NO ☐ DID ASSOCIATE SEEK OUTSIDE MEDICAL PRIOR TO REPORTING INJURY TO SITE? YES ☐ NO ☐ DID THE INJURY OR ILLNESS REQUIRE ANY MEDICAL TREATMENT BEYOND FIRST AID? YES ☐ NO ☒ NOTE- WHEN INPUTTING INTO AUSTIN ALWAYS SELECT “NO” FOR THIS. THE SAFETY SPECIALIST WILL ADJUST LATER ON ONCE FURTHER DOCUMENTATION IS PROVIDED. RISK GROUP RISK CATEGORY Choose an item. Choose an item. RISK HAZARD – MUST BE SELECTED IN AUSTIN AFTER THE ABOVE DROP DOWNS ARE SELECTED Page 3 of 10 INJURY AND ILLNESS INVESTIGATION FORM USE THE FOLLOWING CHART TO DETERMINE THE LIKELYHOOD OF OCCURRENCE AND POTENTIAL SEVERITY HOW LIKELY WILL THE INCIDENT REOCCUR? VERY UNLIKELY ☐ UNLIKELY ☐ POSSIBLE ☐ LIKELY ☐ VERY LIKELY ☐ WHAT IS THE POTENTIAL SEVERITY IF THE INCIDENT REOCCURED? NEGLIGIBLE ☐ MINOR ☐ SIGNIFICANT ☐ Page 4 of 10 MAJOR ☐ EXTENSIVE ☐ INJURY AND ILLNESS INVESTIGATION FORM Investigation PLEASE TAKE ANY DOCUMENTATION (PICTURES, WITNESS STATEMENTS, PPE CONDITION, ETC.) GATHERED FROM THE INVESTIGATION AND ATTACH IN THE INVESTIGATION SECTION OF THE CASE IN AUSTIN. PLEASE DO NOT UPLOAD YOUR INJURY REPORT IN THIS SECTION. ADD PICTURE, ASSOCIATE CHARACTERISTICS, AND OTHER INFORMATION REGARDING THE INVESTIGATION. YES ☐ AA wearing appropriate PPE properly? NO ☐ Notes: YES ☐ Did someone witness this? NO ☐ If so, attach witness statements to the investigation section of the case. YES ☐ AA able to return to work? NO ☐ If Yes, provide date/time AA returned to work. If No, explain why the AA did not return to work. Notes: AA’s Date of Hire: Click or tap to enter a date. Was AA working Overtime, Mandatory Extra Time, or Voluntary Extra Time? YES ☐ NO ☐ Notes: Detailed location of incident (station number, etc.): YES ☐ Does process path require rotation? NO ☐ If yes, when was AA last rotated? Notes: Work area cluttered or congested? YES ☐ NO ☐ Was equipment involved in the incident? YES ☐ NO ☐ NOTE EQUIPMENT INVOLVED: YES ☐ Was AA injured by a product? NO ☐ PRODUCT (INCLUDE ASIN & WEIGHT): Which policy/procedure is linked to the task the AA was performing? (PMV, Safety Standard of Conduct, etc): Is AA trained in the above policies/procedures? YES ☐ If “YES” on what date? Click or tap to enter a date. If “NO”, reason for not being trained? N OTE: Page 5 of 10 NO ☐ INJURY AND ILLNESS INVESTIGATION FORM ** PLEASE PROVIDE REQUIRED PHOTO’S ** Include reenactment photos below using a snippet of the photo. DO NOT UPLOAD A FILE INTO THIS DOCUMENT – AUSTIN WILL NOT ACCEPT TOO LARGE OF A FILE SIZE: Note: PPE should always be worn when recreating incidents (regardless of if the injured AA was wearing PPE or not). Additionally, any identifying information (face, badge, etc.) should be blurred out from the photos. Page 6 of 10 INJURY AND ILLNESS INVESTIGATION FORM Root Cause Analysis INSTRUCTIONS: SELECT “UPLOAD A COMPLETED ROOT CAUSE ANALYSIS FILE (E.G. A3 REPORT)” AND UPLOAD THIS DOCUMENT TO THIS SECTION IN AUSTIN ONCE COMPLETE. UTILIZE THE HUMAN FACTORS GUIDE TO ASSIST IN COMPLETING THE INFORMATION BELOW. WHEN ADDING YOUR ACTIONS REMEMBER THE LONG-TERM ACTION IS INPUTTED IN STEP 2 OF THE ROOT CAUSE ANALYSIS PHASE. ALL OTHER ACTIONS ARE INPUTTED INTO THE “ACTIONS” SECTION OF THE INCIDENT IN AUSTIN. Page 7 of 10 INJURY AND ILLNESS INVESTIGATION FORM PROVIDE RESULTS: CONTRIBUTING FACTOR CATEGORY Choose an item. CONTRIBUTING FACTOR (OPTIONAL) Choose an item. PRIMARY CAUSE – THE PRIMARY CAUSE MUST BE SELECTED IN AUSTIN BASED ON THE ABOVE 2 OPTIONS ROOT CAUSE – THE ROOT CAUSE MUST BE SELECTED IN AUSTIN BASED ON THE ABOVE 3 OPTIONS COMMENTS: *PASTE DESCRIPTIVE ROOT CAUSE FROM 5-WHY HERE* Complete 5-WHY Analysis and Root Cause Statement (To view an example 5-WHY CTRL click HERE or scroll to the end of this template!): Problem Statement: WHY? 1. WHY? 2. WHY? 3. WHY? 4. WHY? 5. WHY? (Root Cause) Descriptive Root Cause (Copy and Paste From #5 Above) "The highest-level cause that sets in motion the entire cause-and-effect reaction that ultimately leads to an incident" Descriptive Causal Factor(s) (Contributing Factors or Immediate Causes) “A mistake, error, or failure that directly leads to (or causes) an Incident or fails to mitigate the consequences of the original error" Page 8 of 10 INJURY AND ILLNESS INVESTIGATION FORM Corrective Action(s): Corrective action(s) for Root Cause (long term) 1. Other corrective actions (short term) 1. 2. Austin Link: *Insert Austin Link to Incident Case* Note: 1. A minimum of 2 immediate/short term actions must be documented within 24 hours in Austin. 2. A minimum of 1 long-term action and they’re due 15 days from creation. Any extensions will need to be approved by WHSM and Sr. Leadership team Page 9 of 10 INJURY AND ILLNESS INVESTIGATION FORM EXAMPLE DESCRIPTION & 5-WHY: DESCRIPTION: AA’s Account of incident – (Automatically inputted in Austin from Initial Report) AM’s Account of incident - On 6/30/2021 at approximately 01:00 AM an Amazon Associate working in Smart Pac at station 06-12 reported a 5/10 pain level in their right shoulder while pulling the roll cover off the front of a label spool. Upon removing the roll cover, the AA noticed that the roll cover was taped to the SLAM label machine. The AA came to AM regarding pain in their right shoulder and the AM escorted the AA to the Wellness Center. Safety was unable to pull any camera footage due to no cameras being in the area. The associate was found to be hired on April 7, 2021, and completed Smart Pac training on May 10, 2021. The associate WAS being labor shared. The investigation identified the associate WAS wearing their PPE at the time of the incident. The associate WAS NOT currently working mandatory overtime. After reporting their injury, the associate WAS able to return to their process path. The root cause of the injury was found to be that the securement latch on roll cover was damaged and was not fixed/replaced. In response to this injury, the AM will place signage on all Smart Pac machines instructing AAs to not use tape to secure roll cover to SLAM label machine. Operations will also Coach AA’s on proper escalation of out-of-standard conditions of equipment (red tag process) and implement area readiness checklist to ensure stations/equipment are in good condition before use. These actions will be entered into Austin and tracked to completion. Complete 5-WHY Analysis and Root Cause Statement: Problem Statement: AA experiencing discomfort in right shoulder WHY? 1. AA strained shoulder pulling on roll cover WHY? 2. Roll cover was taped to the SLAM label machine WHY? 3. Roll cover was taped to the machine because existing securement latch was not functional WHY? 4. Securement latch was broken during previous roll replacement and was not fixed WHY? 5. Roll cover was not red tagged/RME was not notified Page 10 of 10 WHY? (Root Cause)
