Agriculture Employee Incident Report

I. Introduction

This report helps [Your Company Name] investigate and address safety concerns, prevent future incidents, and ensure compliance with all safety regulations. Accurate and timely reporting is crucial for maintaining a safe work environment.

II. Employee Information

Name of Employee
Job Title
Department
Supervisor
Contact Information

III. Incident Details

Date of Incident
Time of Incident
Location
Weather Conditions

IV. Description of Incident

Provide a detailed description of the incident, including the sequence of events leading up to the incident, the actions taken by the employee, and any equipment or tools involved.

At approximately 10:30 AM, Employee was performing routine maintenance on the irrigation pump in Field 7. While attempting to adjust a valve, the wrench slipped, causing Employee to lose his balance and fall backward. He landed on a rocky surface, injuring his left arm and lower back. The irrigation pump was running at the time, but no further mechanical issues were noted.

V. Witnesses

List the names and contact information of any witnesses to the incident.

Witness	Name	Contact Information
1
2

VI. Injuries and Damages

Document any injuries sustained by the employee or others involved, as well as any damage to property or equipment.

Injuries: Employee sustained a sprained left wrist and bruising on his lower back. No other employees were injured.
First Aid or Medical Treatment Provided: Employee was given first aid on-site by the supervisor and was then transported to the local clinic for further evaluation. He received an X-ray and was advised to rest for a few days.
Damage to Property/Equipment: No damage to the irrigation pump or other equipment was noted.

VII. Immediate Actions Taken

Describe any immediate actions taken to address the incident, including emergency responses, containment measures, and notifications to supervisors or emergency services.

Supervisor immediately stopped the irrigation pump and provided first aid to Employee. Witness contacted the local clinic to arrange for [Your Company Name]'s transportation. The incident was reported to the safety officer, and the area around the pump was secured to prevent further accidents.

VIII. Root Cause Analysis

Analyze the root causes of the incident to identify any underlying factors that contributed to the occurrence. Consider environmental conditions, equipment malfunctions, human error, and procedural issues.

The primary cause of the incident was the loss of balance due to the slipped wrench. Contributing factors include the uneven, rocky surface where John was working and the potential need for more secure footing or supportive equipment while performing maintenance tasks.

IX. Corrective Actions

Outline the corrective actions that will be taken to prevent a recurrence of the incident. This may include changes to procedures, additional training, equipment repairs or replacements, and other preventive measures.

Conduct a safety review of all maintenance procedures related to the irrigation pump.
Provide additional training to employees on the use of tools and proper body mechanics to prevent falls.
Install anti-slip mats or platforms around high-risk areas, such as the irrigation pump.
Ensure that all employees are equipped with appropriate personal protective equipment (PPE), including gloves and safety shoes.

X. Follow-Up

Detail any follow-up actions required, including further medical evaluations, equipment inspections, and ongoing monitoring to ensure the effectiveness of corrective measures.

Schedule a follow-up medical evaluation for Employee in one week to assess recovery progress.
Inspect the irrigation pump and surrounding area for any additional hazards.
Monitor the implementation of new safety measures and conduct periodic reviews to ensure compliance and effectiveness.

XII. Reporting and Documentation

Ensure that all necessary reports and documentation are completed and submitted to the appropriate parties, including internal safety committees and external regulatory agencies if required.

Internal Safety Committee
Human Resources Department
Local Occupational Safety and Health Administration (OSHA) office

Signatures

Employee

[Name]

[Title]

[Date]

Supervisor

[Name]

[Title]

[Date]