[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-244639-105":53,"doc-detail-244639-en":127},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","root-cause-analysis-of-injuryillness-supplemental-form","Root Cause Analysis of Injury/Illness - Supplemental Form","","Supplemental root cause analysis form for investigating an injury or illness incident. Captures injured employee details and context questions about tasks performed, equipment used, whether the employee worked alone, and relevant experience. Guides investigators through evidence collection (physical, people, paper), identification of direct, contributing, and root causes across policy/programs, hazards, communication, facilities/equipment, productivity, training, patient handling, work behavior, environment, and blood/OPIM exposure, then drills down with repeated “why” analysis and prevention-oriented corrective steps.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/root-cause-analysis-of-injuryillness-supplemental-form/244639/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/root-cause-analysis-of-injuryillness-supplemental-form/244639.png","ImageObject",442,249,{"name":88,"@type":89},"Jordan Avery","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-22","2026-09-12",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",9,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What information is collected about the injured employee and the situation before the incident?","Question",{"text":109,"@type":110},"The form records the injured employee name and asks what task was being performed, what tools/machinery/equipment were used, whether the employee worked alone (and if with someone), and the injured person’s experience with the task.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What evidence should be gathered during Step 1?",{"text":114,"@type":110},"Step 1 requires collecting physical evidence (e.g., sample results, photographs, drawings, equipment manuals), people evidence (witness statements and interviews, employee report of incident), and paper evidence (policies, programs, procedures, training records, maintenance records, prior incident reports).",{"name":116,"@type":107,"acceptedAnswer":117},"How does the form identify root causes and determine corrective actions?",{"text":118,"@type":110},"Step 2 provides categories to check for factors that led to the incident, and Step 3 asks to circle the major cause(s) by category. Step 4 then uses repeated “Why” questions to analyze root cause and concludes with how prevention can be achieved and corrective steps for direct, contributing, and root causes.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},244639,1790105868,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":76,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":9},1099523882367,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","ROOT CAUSE ANALYSIS OF INJURY/ILLNESS  \n(Supplemental Form)  \nInjured Employee Name:    \n1. What task was the injured employee performing prior to the accident / near miss?    \n2. Describe any tools, machinery or equipment that was being used at the time of the incident?    \n3. Was the employee working alone? Yes No With?    \n4. How much experience did the injured person have in performing this task?    \nSTEP 1 – OBTAIN AND REVIEW PHYSICAL, PEOPLE, AND PAPER EVIDENCE PERTINENT TO THE INVESTIGATION.  \n• Physical: Sample Results (Air, Noise, Bulk, etc.)/ Photographs/Drawings/Equipment Manual/etc.  \n• People: Witness Statements & Interviews/ Employee Report of Incident  \n• Paper: Policies/Programs/Procedures/Training Records/Maintenance Records/Prior Incident Reports/etc.  \nSTEP 2 – DIRECT, CONTRIBUTING, AND ROOT CAUSES  \n• Use this listing as an aid for identifying the factors that lead to the incident.  \n• Don’t be limited by the categories listed--add items (Other) as needed. Check all that apply.  \nPOLICIES/PROGRAMS  \n✓  \n\n| Not Developed or Inadequate |  |\n| --- | --- |\n| Developed – Not Communicated |  |\n| Developed – Not Understood |  |\n| Developed – Not Followed |  |\n| Lack of Disciplinary Policy |  |\n| Disciplinary Policy Not Enforced |  |\n| Other |  |\n|  |  |\n\nHAZARD(S)  \n✓  \n\n| Unidentified or Not Labeled |  |\n| --- | --- |\n| Known But Not Corrected |  |\n| Known But Not Reported |  |\n| Created By External Factors |  |\n| Documented But Not Repaired |  |\n| Condition Changed Not Conveyed |  |\n| Equipment Repaired Deficiently |  |\n| PPE Not Adequate or Defective |  |\n| Other |  |\n\nCOMMUNICATION  \n✓  \n\n| Insufficient Planning for Tasks |  |\n| --- | --- |\n| Lack of Worker Communication |  |\n| Lack of Supervisor Instruction |  |\n| Work Team Breakdown |  |\n| Confusion After Communication |  |\n|  |  |\n| Other |  |\n|  |  |\n\nFACILITIES/EQUIPMENT  \n✓  \n\n| Poor Facility Design |  |\n| --- | --- |\n| Poor/Faulty Equipment Design |  |\n| Awkward Workstation Design |  |\n| Equipment Not Guarded |  |\n| Equipment Repair Deficient |  |\n| Lack of Preventive Maintenance |  |\n| Lack of Storage |  |\n| Other |  |\n|  |  |\n\nPRODUCTIVITY FACTORS  \n✓  \n\n| Heavy Workload |  |\n| --- | --- |\n| Tight Schedule |  |\n| Long/Unusual Working Hours |  |\n| Falsely Perceived Need to Hurry |  |\n| Staff Assistance Unavailable |  |\n| Staff Assistance Inadequate |  |\n| Changes in Process |  |\n| Other |  |\n|  |  |\n\nTRAINING  \n✓  \n\n| Deficient Orientation Training |  |\n| --- | --- |\n| Deficient Job-Specific Training |  |\n| Insufficient Training for New Process/Task |  |\n| Lack of Supervisor Follow-Up/Reinforcement |  |\n| Lack of Supervisor Training |  |\n| Hazards Overlooked in Training |  |\n| Other |  |\n\nPATIENT HANDLING  \n✓  \n\n| Transfer/Positioning Equipment Not Used |  |\n| --- | --- |\n| Transfer/Positioning Equipment Not Used Properly |  |\n| Transfer/Positioning Equipment Not Available |  |\n| Equipment Not Adequate for Patient Weight and/or Size |  |\n| Area too Small to Use Transfer/Positioning Equipment |  |\n| Combative Patient |  |\n| Care Plan Not Adequate |  |\n| Care Plan Did Not Fit Patient Handling Policy |  |\n| Care Plan Not Updated When Patient Condition Changed |  |\n| Care Plan Not Followed |  |\n| Other |  |\n|  |  |\n\nWORK BEHAVIOR  \n✓  \n\n| Shortcuts Taken |  |\n| --- | --- |\n| Required PPE Not Used |  |\n| PPD Not Used Properly |  |\n| Tool/Equipment Used Incorrectly |  |\n| History of Accidents/Incidents |  |\n| Disregarded/Refused to Follow Procedure(s) |  |\n| Staff Assistance Required – Not Requested |  |\n| Horseplay |  |\n| Other |  |\n\nENVIRONMENT  \n✓  \n\n| Weather, Temperature |  |\n| --- | --- |\n| Poor Housekeeping |  |\n| Poor Lighting |  |\n| Poor Visibility |  |\n| Air Quality |  |\n| Noise |  |\n| Other |  |\n\nBLOOD & OPIM EXPOSURE  \n✓  \n\n| Needless System Not Available |  |\n| --- | --- |\n| Needless System Available-Not Used |  |\n| Needle Device (needle cover, etc.) Not Used |  |\n| Sharps Container Not Located as Close as Feasible |  |\n| Sharps Container Overfi","cbCaifJzWR4w1nDQ","https://ap.wps.com/l/cbCaifJzWR4w1nDQ","pdf",220983,"English","# Injured Employee Information\n# Evidence Collection (Step 1)\n# Direct, Contributing, and Root Causes (Step 2)\n## Policies/Programs\n## Hazards\n## Communication\n## Facilities/Equipment\n## Productivity Factors\n## Training\n## Patient Handling\n## Work Behavior\n## Environment\n## Blood & OPIM Exposure\n# Cause Identification (Step 3)\n# Root Cause Analysis (Step 4)\n## Why Analysis\n## Prevention and Corrective Steps\n# Signatures and Dates","[{\"question\":\"What information is collected about the injured employee and the situation before the incident?\",\"answer\":\"The form records the injured employee name and asks what task was being performed, what tools/machinery/equipment were used, whether the employee worked alone (and if with someone), and the injured person’s experience with the task.\"},{\"question\":\"What evidence should be gathered during Step 1?\",\"answer\":\"Step 1 requires collecting physical evidence (e.g., sample results, photographs, drawings, equipment manuals), people evidence (witness statements and interviews, employee report of incident), and paper evidence (policies, programs, procedures, training records, maintenance records, prior incident reports).\"},{\"question\":\"How does the form identify root causes and determine corrective actions?\",\"answer\":\"Step 2 provides categories to check for factors that led to the incident, and Step 3 asks to circle the major cause(s) by category. Step 4 then uses repeated “Why” questions to analyze root cause and concludes with how prevention can be achieved and corrective steps for direct, contributing, and root causes.\"}]","Root Cause Analysis of Injury/Illness - Supplemental Form | PDF",1789220253]