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SUGGESTED FORMAT FOR
DETAILED REPORT ON EMPLOYEE INCIDENTS
(Confidential Internal Use Only)
1. Heading on Report
The heading of the report shall incorporate in the following order:
(a) The reference, "Employee Incident."
(b) The name of the region, project, and station involved.
(b) The name of the region, project, and station involved.
(c) The name, job title, and grade of personnel involved.
(d) The date of the occurrence.
(d) The date of the occurrence.
(e) Incident definition, from PO&M-171.
2. DESCRIPTION OF OCCURRENCE
Give as concisely as possible in the order undernoted a comprehensive description of the occurrence.
Include all relevant information which would assist in conveying a clear understanding of what took place
and the reasons for it, or which would be helpful in arriving at a judgment of the correctness of the
conduct of the parties concerned. A statement such as: Inattention to job at hand, is not
sufficient.
Include all relevant information which would assist in conveying a clear understanding of what took place
and the reasons for it, or which would be helpful in arriving at a judgment of the correctness of the
conduct of the parties concerned. A statement such as: Inattention to job at hand, is not
sufficient.
(a) Events leading up to the occurrence, with remarks on time available, stress, disturbing,
or distracting factors.
or distracting factors.
(b) The fault occurrence.
(c) The results, injuries, damage, service impairment.
(c) The results, injuries, damage, service impairment.
(d) The restoration of service.
(e) Supplementary diagrams and sketches as required.
(e) Supplementary diagrams and sketches as required.
3. TITLES AND DUTIES
Indicate the titles and duties of the parties directly involved:
(a) Normal duties.
(b) Special duties, if there was any departure from the normal during the period under
consideration.
(b) Special duties, if there was any departure from the normal during the period under
consideration.
4. BOARD OF REVIEW ANALYSIS AND RECOMMENDATIONS
(a) Reduce the incident to the simplest possible statement of what took place from a point
of view of conduct, especially commendable.
of view of conduct, especially commendable.
(b) Comment on the correctness of conduct and the degree thereof, and mention any
extenuating circumstances.
extenuating circumstances.
(c) Indicate briefly the factors that would best summarize the incident as to cause. Attempt
to answer such questions as: Incident in judgment? Failure to communicate?. Better or more
extensive training needed? Management action needed? Inadequate facilities?
Manufacturer/Design/Construction involvement?
to answer such questions as: Incident in judgment? Failure to communicate?. Better or more
extensive training needed? Management action needed? Inadequate facilities?
Manufacturer/Design/Construction involvement?
(d) State corrective actions recommended in light of the causes identified in 4(c) above. (Be
specific.)
specific.)
Figure 5. - Suggested format for detailed report on employee incident.