This document provides a risk analysis of the St. Cloud Sports Arena (SCSA) in St. Cloud, Minnesota. It outlines various risks associated with operating the arena, including risks to spectators and athletes, and categorizes them based on severity and frequency. It also provides examples of potential treatments for each risk category, including avoidance, transfer, reduction, and retention strategies. Specific risks addressed include injuries, vandalism, power outages, fires, and more. The document discusses emergency procedures, sexual harassment policies, and other risk reduction measures to help ensure safety at the arena.
3. 3SCSA RiskAnalysis
Overview
The St. Cloud Sports Arena is a multipurpose arena located in St. Cloud, Minnesota. Our
arena here is LEED (Leadership in Energy & Environmental Design) certified to help eliminate
over usage of energy and other resources. Our arena seats 70,000 spectators for our wide
variety of events we put on here at our facility. Our arena is compliant with all ADA (Americans
with Disabilities Act) regulations. Our arena plays host to a number of different events,
including; high school basketball tournaments, college basketball, professional basketball
events, concerts, music award shows, comedy specials and even some WWE shows. Our venue
holds a sizeable amount of vehicles for personal vehicle parking. We have ramps for parking, as
well as outside parking with twenty five spaces for people with disabilities, twenty parking
spaces for motorcyclists, seven stationary bike racks and four hundred and fifty spaces available
for personally operated vehicles. The SCSA is the primary stakeholder of this venue. Our local
community surrounding the arena will see a significant increase in revenue, especially during
basketball season. Our arena here is incredibly versatile, which is why we are able to play host
to a multitude of events. We have several teams here of risk management personal here to
ensure your safety when you come to our arena. We have three teams of five people at the
arena who are in charge of different areas involving our risk management policies. We also
have eighty other employees who are employed for emergency situations, crowd management,
and maintenance protocols when the facility is operating at, or near maximum capacity. Those
specific teams will consist of teams of three with a team leader running the show. These teams
will essentially be part of a squad consisting of nine people or three separate teams, and each
of those squads will belong to a platoon which consists of three squads. We use this model to
4. 4SCSA RiskAnalysis
keep our employees responsible and accountable if there ever were to be an emergency during
an event. We also have a state of the art security video surveillance systemthat keeps an eye
out for any suspicious behavior and activity during an event. The surveillance systemhub will
be known as the Tactical Operations Center (TOC).
Risk Category Matrix
Severity &
Frequency
Catastrophic
Loss
Critical Loss Moderate Loss Low Loss
High *Athlete suffers
a sprain while
competing
*Spectators
attempting to
counterfeit
tickets
*Spectators
converging
around heavy
traffic areas
Medium *Athlete suffers
heat exhaustion
*Fan slips or
trips in parking
lot or arena
*Athlete suffers
a major injury to
knee during a
* Vehicles are
vandalized due
to lack of lighting
*Spectators
littering in and
around the arena
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game *Drunk fans
vandalize arena
property
Seldom *Spectator dies
from medical
condition
*Spectator has a
weapon that has
a negligent
discharge,
injuring an
innocent person
*Athlete suffer a
spinal injury
during a game
*Roof begins to
leak on fans
during a game
*An employee
starts a fire due
to smoking in
undesignated
area of arena
*Fans suffering
from food
poisoning due to
improper storage
of food
*Power outage
during an event
*Overstressed
employee
verbally assaults
a spectator
Our most important focus here at SCSA is that are spectators having an enjoyable time every
time they walk through those doors. Even more our spectator’s safety is the most important
thing to us here at SCSA. Our nation will always be kept up to date to ensure that our facility
runs the absolute best of its ability so that it can be the safest, best functioning and best overall
arena in the nation for our wonderful community and fans.
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Risk Treatment Matrix
Severity & Frequency High Loss Moderate Loss Low Loss
Often Avoid Transfer & Reduction Transfer or Retain &
Reduction
Average Avoid or Transfer &
Reduction
Transfer & Reduction Retain & Reduction
Seldom Transfer & Reduction Transfer or Retain &
Reduction
Retain & Reduction
Ten Specific Risks
We have outlined ten specific risks that are associated with our arena and we have them
rated on a scale from catastrophic, critical, moderate and low. The frequency we have listed for
those risks are high, medium and seldom. More risks are more than likely to happen than just
the ten that we have specified and outlined, but we believe that the ten we have identified are
the most common to uncommon risks that are involved with our arena. They are also labeled
with a risk treatment matrix. The examples given start with a low loss category with financial
and reduction treatments. These treatments aren’t limited, and provide guidance in the event
of an occurrence of the specific risk being identified.
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Low Loss
Examples of risks that are high frequency, but low in loss are spectators attempting to
make counterfeit tickets, dealing with employee theft and fans converging around heavy traffic
areas. We will use a financial and reduction treatment to help prevent counterfeit tickets by
having color coded tickets and also by watermarking the tickets. Ways to reduce employee
theft are by having security cameras around cash registers and throughout the entire arena to
help prevent theft by all. It can also be minimized my employees not being allowed to bring
large bags into work with them. We will also have staff members at our arena ensuring that
large groups of people do not converge around fire traffic areas, or normally heavy traffic areas.
These issues will be retained and reduced to the facilities budget plan. Transference can be
utilized in the event of a large heist or counterfeit scheme by the arenas insurance policy.
Medium frequency and low in loss risks examples are vehicles being vandalized due to
insufficient amount of lighting in arena parking lots, spectators littering in and around the arena
and drunken fans vandalizing arena property. Solving the vandalismissue in our parking lots
should be relatively easy, we just need to increase and maintain our lighting better in and
around the parking lots during night events. A good solution would be to incorporate the use
of solar powered lighting being set to power on at sunset until sunrise. The reduce of vehicle
break ins can be solved by having more staff and security circulate throughout the parking
areas during facility operation and post operation to assure that no vehicles are being
vandalized. More staff around concession areas in the arena to help reduce spectators littering
their trash around the facility. More staff needed around at the conclusion of an event to help
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prevent drunken and disorderly fans from vandalizing arena property. Here at SCSA we will
take all the necessary precautions to best minimize the risk of vandalismat our facility. If an
event of theft occurs will make sure that we offer as much assistance as needed for the victim.
Seldom frequency and low in loss risks are fans suffering from food poisoning due to
improper storage of food, power outage during an event and an overstressed employee
verbally assaulting a spectator. We keep are food services held at the highest standards for
food services. The facility is mostly outsourced when the facility is being leased for an event,
but we will go through proper procedures when handling food for concession usage. All risks
will be transferred to the leasing agency for any sickness assumed from improper food storage.
Improper food storage has the potential to cause spectators to become ill after consuming such
products from concession stands. This risk is easily avoidable if all members that work in food
are properly trained in on proper food safety. Working with food you must be required to
handle food with proper safety and equipment to help prevent the transfer of sicknesses that
can be passed if food is prepared incorrectly.
Moderate Loss
Other risks that are high in frequency and moderate in loss are an athlete spraining a
body part particularly an ankle during athletic competition. Reasons for an athlete spraining
their ankle could stem from the intense competition the athlete is facing, or it could be due to
the floor being slick and slippery from sweat. To help reduce this particular risk as best as
possible we will have on court staff members to help clean up wet spots on the court as best as
possible during athletic competition. Proper maintenance and care to the hardwood floor will
9. 9SCSA RiskAnalysis
surely help lower the overall risk of injury to an athlete during competition. There are
precautions that athletes can use themselves to help reduce the risk of this happening to them,
such as stretching before their game begins. In almost every case the facility will use a
retention or transference plan to accommodate this risk, if the reduction methods were to fail.
The insurance policy will cover almost all the minor injuries, and medical assistance will be
provided to any athlete who suffers an injury.
Risks that occur at medium risk and have a moderate loss are fans slipping or tripping in
parking lot or arena and athlete suffering a major injury to their knee during a game.
Spectators are always at risk of falling especially when outside due to Mother Nature and its
many conditions, as well as inside the arena where they may occasionally be a spill, or wet
floors from mopping. If there is inclement weather outside the facility we will notify our
maintenance workers to clean up the parking lot and walkways to and from the arena for our
spectators. If a spillage were to occur inside the arena it will be properly cleaned up as soon as
possible and all spectators will be aware of the spill has occurred, so that they can best avoid
that area. If a fan were to slip and fall on or in the facility grounds as a result of negligence on
the facilities behalf, transference from us, the policy holder, to the insurer will assist in limiting
the potential monetary damages that result from a slip and fall accident.
Seldom, but moderate risks that may occur at our facility are the roof begins to leak on
fans during a game or event, and an employee starts a fire due to smoking in undesignated area
of the arena. Maintenance of the roof will be consistently done every year before notable rain
and snowfall occur to identify any possible hazards that might cause a catastrophic leak into our
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facility. Any noticeable signs of damage potential will be monitored and fixed to assure that we
do the best to reduce the risk of this happening at our arena. Another possible risk is an
overstressed employee smoking in an undesignated area of the arena. Employees know where
there designated smoking areas are at the facility, and if seen smoking where not allowed they
will be reprimanded. In an unlikely event of a fire breaking out there are fire extinguishers all
around the arena in convenient places. All of these potential risks identified in the seldom but
moderate loss section can be transferred to the outsourced insurance agency under policy in
order to assist in repairing damages associated with these risks.
Critical Loss
Critical loss risks are heat related injuries, or an injury that could cause paralysis to an
athlete. It is easy to mitigate the cause of heat related injuries, by keeping the arena at a
comfortable temperature especially during warm summer months. There are plenty of water
sources in the arena. In the unlikely event of an athlete or spectator suffering from a heat
related injury, medical staff will be on hand and ready to assist you immediately. If an athlete
would suffer a spinal cord or neck injury during competition medical staff will assist you as best
as they can, but ambulance services will be provided if this were to happen.
Catastrophic Loss
An example of a catastrophic loss would be a death of an athlete, or an unforeseen
death of a spectator. Events like these can cause the facility a severe loss. In most cases death
11. 11SCSA RiskAnalysis
of a spectator at an event is most commonly by the spectator already being ill, or suffering from
a stroke or heart attack. If this were to happen, our medical staff on hand would do everything
in its power to help that individual, but our ultimate goal would be to get that individual to the
nearest hospital as soon as possible to help save that person’s life. In an unfortunate event that
the spectator arrives at the hospital already deceased, necessary actions will take place to
transport the deceased and family to a medical facility as soon as possible. Additional concern
in this section include the potential or event of a person, who is illegally carrying a weapon on
the premises of the arena, negligently discharging a firearm that results in the death of another
innocent spectator. There will proper postage all round our facility that states what will happen
to you if you decide to carry illegal weapons on facility premises. We will have medical
detectors as you walk into the arena to best reduce the risk of this awful event ever occurring.
Transference will be utilized in the event of these catastrophic emergencies.
Indemnification Clause
In an indemnification clause the lease’e will defend, indemnify and hold harmless the
leasor, from and against all costs, charges and expenses arising out of the usage of the facility.
Any leasing of the facility in sporting events will be subject to review by the facility manager.
The risk involved with the sporting event in the arena will be transferred to the leasing party
and the facility will not be held liable for any injuries associated with the activity.
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Waivers
We will have waivers in place so that we can make sure that our arena will not be sued
due to negligence that may result in an injury of a plaintiff. Major sporting competition that
involves the possibility of getting injured, the athletes participating will be asked to sign a
waivers. Before signing the waiver, we recommend getting legal advice from an attorney, so
that you know exactly what you are signing when you come to our arena. In the event of
leasing the facility to outside entities, waivers will need to be provided by the lease’s. The
arenas release, waiver, indemnity and assumption of risk form is located in appendix A.
Risk Reduction
Our staff and maintenance crew will be trained, certified, tested and employed to our
specific certification in order to properly maintain the facility. Employees will be included in the
development of the risk management to ensure that success of the plan. All risk management
plans will be available to our employees at orientation. We have the right to random drug test
any employee in which we see fit, so that we can keep our facility one hundred percent drug
free, as well as help reduce on the job accidents. A reduction technique will be utilized in the
employee sections of the facility through advertising in and around our arena that we are
indeed a drug-free facility. Before we hire any employee, we go over the following; job
descriptions, job title, job duties, responsibilities, qualifications, start date and the name and
address of the contact.
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Sexual Harassment
At our arena sexual harassment training is necessary and mandatory, and we cannot
stress enough how each and every employee must understand the severity that sexual
harassment can bring. Our facility will be an enjoyable and comfortable environment for our
employees to come work in. There will be no harassment tolerated based on gender, or
anything else for that matter. If you are sexually harassing a co-worker you will be
reprimanded and possibly terminated from our facility. Our sexual harassment form can be
found in appendix B.
Facility Emergency Procedures
Emergencies procedures and risks associated with the reactionary procedures will be
assessed and reassessed by our teams at our arena to ensure that our spectators are safe when
they step inside our facility. We will test our emergency management plans to make sure that
they are prepared to the best of our ability in case of an emergency. Our arena Emergency
Planning Team (EPT) will be in charge of developing, implementing, and reevaluating and
updating the emergency plan. We will classify the different types of emergencies as; local
emergencies, major emergencies and catastrophic emergencies. Local emergencies are lower
scale emergencies that would involve local law enforcement, or medical personnel. Here are a
couple examples of what we would classify as a major emergency; fires, structural disasters, or
riots. Catastrophic emergencies would be the largest scale type of emergency that would more
than likely require federal, state and local agencies for emergencies such as tornadoes,
earthquakes and severs storms.
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If an emergency ever were to occur, our staff have their designated areas and
responsibilities to facilitate the emergency procedures. The emergency procedures will be
planned out and executed with safety and accuracy. Emergency alerts will be broadcasted by
color codes over our PA system from the central command post inside the arena in order to
keep consistency within the emergency procedure initiation system. Accidental body injuries
will be reported as ‘Green’ and will be assisted by the team in specific sectors for their area of
operations. Medical staff will be notified immediately following an injury. We will two teams
tasked with dealing with crowd management while our emergency medical staff tend to the
injured person. If there are behavioral issues with spectators, this situation will be color coded
‘Yellow’. Yellow emergency codes will require one to two teams in order to separate parties
and control the situation to the best of their capabilities. The person or party that initiated the
issue will be asked to exit the facility, and local law enforcement will be called upon if need be.
We will keep on record if anyone is indeed ejected from the arena during an event. Our
security team will be trained to understand the concepts of the reasonable person theory and
excessive force in order to mitigate potential lawsuits against our facility. Emergency situations
will be color coded as ‘Red’. Red codes will more than likely be dealing with natural disasters.
All emergency personnel on hand will report to designated areas and First Aid Stations to equip
and prepare for response. Crowd management teams will be asked to report to their
designated areas to help assist in facility movements of spectators to safe parts of the arena.
Staff are to try and keep the spectators as calmas humanely possible, while making sure that
everyone is safe and alright. Spectators with disabilities will be handled with care, and assisted
at each and every level possible in an emergency situation. If evacuation would become
15. 15SCSA RiskAnalysis
necessary, spectators with disabilities will be evacuated through a separate area to allow for
ease of movement. An accident report form can be found in appendix C.
Crowd Management
We will have sufficient crowd management on hand, so that our spectators have a safe
and enjoyable time at our arena. Our searchers are hand of extremely high importance and the
first barrier of our crowd management team, in order to turn away prohibited items and check
peoples tickets. Secondly, the ticket takers will inspect all tickets to make sure none are
counterfeit and accept tickets from attendees. The ushers will also assist in crowd services.
The ushers will be required to be familiar with the facility, location of important facility services
and asset anyone who may need assistance. The crowd management teams will follow the
emergency plan that consists of anticipatory and reactionary components. Anticipatory plans
will consist of situations where the crowd management teams will foresee issues and make
necessary adjustments in order to keep crowd congestion at a minimum and crowds under
control. Reactionary components consist of emergency plans for the management of the
crowd in response to an emergency. Disruptive, unruly or intoxicated patrons will be handled
accordingly to the standard operating procedures that ensure the safety of all patrons on the
premises. Our trained crowd management personnel and security team will handle all of the
necessary ejections and this will properly reported and documented for records of this
occurrence.
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Americans with Disabilities Act Compliance
Our arena will be compliant with ADA regulations to ensure that all disabled persons who
attend our facility will be treated just like anyone else and with the upmost respect, and having
a delightful time at our arena. Almost all areas at our arena is wheel chair accessible and wheel
chair seating also comprises about 3% of the arena total. People who are sing wheel chairs will
not be isolated from the rest of the crowd, and their sight will not be obstructed. All restrooms
areas will have at least one disabled stall, sink and water fountain. We will make sure that all
disabled restroom areas and equipment are compliant with ADA regulations. We will also have
ramps, railings, parking areas and entrances for those who are disabled and these will also be
up to date with ADA regulations. All doors including; the main, the exits and the emergency
exits will be accessible for persons who are disabled. The drop-off and pick-up areas will be
easily noticeable with signage posted at the entrances and exits of our facility, and curb ramps
will be put in place to make wheelchair use easy for travel. We will have visual alarms tested
and maintained for those are hearing disabled in the event of a fire or an emergency. All of our
stairs will be a non-slip surface. Us here at SCSA will do whatever it takes to make sure that our
facility keeps up to date with ADA regulations. The arena will be evaluated to help and make
sure that everything is up to code. We love to get feedback, so we will hand out surveys to
those spectators who do suffer from a disability to help and rate our current accommodations
of the arena. An ADA Compliance Checklist can be found in appendix D.
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Conclusion
Our facility here at St. Cloud Sports Arena located in St. Cloud, Minnesota will provide a
delightful and safe atmosphere for our 70,000 spectators. Our risk analysis will be updated
quarterly to make sure that our arena is up to date to ensure the safety and functionality of our
facility for our spectator’s well-being. Our arena will have sound risk procedures, personnel
management practices, emergency and crowd management procedures, as well as being
compliant with ADA regulations. If we find anything that needs immediate updating, proper
steps will be taken to make sure that we our updated and up to code at all times. We want our
personnel and employees to take a sense of pride and ownership to the overall success of
operations of the arena. We welcome input and safe work practices and you may also be
rewarded. Our crowd management teams will be tested and evaluated quarterly to make sure
that they are following standard procedures and that the employees are also making good
judgement supervision calls. Supervisory plans, inspections, and in-service education plans will
ensure that the employees and staff are held to a high standard and will assist in identifying
issues that need to be resolved as well as increase the overall knowledge through education of
jobs and responsibilities. Risk management is one of the most, if not the most important aspect
in maintaining a functionally operating arena.
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Appendix A
Waiver of Liability
St. Cloud Sports Arena Participant’s Release, Waiver, Indemnity & Assumption of Risk
Participant’s Name: ________________________________ I, the participant or the
participant’s parent/guardian, understand the nature of sports, physical activities and this
participant’s experience. The participant is in good health and in proper physical and mental
condition to participate in sports and other physical activities. I also understand that
participants may become injured during sports and other physical activities. Release, Waiver
and Indemnity Agreement I, for myself, the minor participant (if a minor), my heirs, next of kin,
personal representatives, successors and assigns, do hereby release, waive, discharge, covenant
not to sue and agree to indemnify, save and hold harmless Forney Sports Center, Inc. (FSC) and
Tri-Line Inc. and any of their officers, directors, independent contractors, employees,
volunteers, event holders, event sponsors, event volunteers, shareholders and members from
all liability claims, demands, losses or damages on this participant’s account from participant’s
disability, personal injury, death, property damage, property theft or actions of any kind
including participants travel to and from FSC facilities, caused or alleged to be caused in whole
or in part by the Forney Sports Center, Inc. and/or Tri-Line Inc. and/or any of its officers,
directors, independent contractors, employees, volunteers, event holders, event sponsors,
event volunteers, shareholders and/or members, or otherwise (Released Parties). I further
agree that if, despite this release, I, the participant or anyone on the participant’s behalf makes
a claimagainst any of the above named released parties, I will indemnify, save and hold
harmless any of the above named released parties from any litigation expenses, attorney fees,
loss liability, damages, or costs any may incur as a result of any such claim. Assumption of Risk
Physical activity, by its nature, carries with it certain inherent risks that cannot be eliminated
regardless of the care taken to avoid injuries. Specific injuries and risks vary from one activity to
another. There is a potential for death, serious injury and property loss. The risks include, but
are not limited to, those caused by terrain, facilities, temperature, weather, condition of
athletes, equipment, vehicular traffic, actions of other people, including but not limited to,
participants, volunteers, spectators, coaches, event officials, and/or producers of the event. I
have read the Assumption of Risks paragraph and know, understand and appreciate these and
other risks that are inherent in the activities held at any of the Forney Sports Center, Inc.
locations. I hereby assert that my participation is voluntary and that I knowingly assume all such
risks of death, injury and/or property loss. Acknowledgment of Understanding I have read this
waiver of liability, release, indemnity agreement and assumption of risk, fully understand its
terms, and understand that I am giving up substantial rights, including the right to sue. I
acknowledge that I am signing the agreement freely and voluntarily and intend by my signature
to be a complete and unconditional release of all liability to the greatest extent allowed by law.
____________________________________________ __________________ Signature of
Participant Date ____________________________________________ __________________
Signature of Parent/Legal Guardian of Minor (if under age 18) Date By signing this document,
19. 19SCSA RiskAnalysis
the parent and/or legal guardian does hereby represent that he/she is, in fact, acting in such
capacity and agrees to save and hold harmless and indemnify the released parties described
above from all liability, loss, cost, claimor damage whatsoever which may be imposed upon
said released parties because of any defect in or lack of such capacity to so act and release said
parties on behalf of the minor and the parents or legal guardian.
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Appendix B
Sexual Harassment Policy
We here at the St. Cloud Sports Arena take sexual harassment very serious, all
employees here at our facility must avoid any actions or conduct that could be construed in any
way as sexual harassment.
SEXUAL HARASSMENT POLICY STATEMENT The Company is committed to providing a workplace
that is free from all forms of discrimination, including sexual harassment. Any employee's
behavior that fits the definition of sexual harassment is a form of misconduct which may result
in disciplinary action up to and including dismissal. Sexual harassment could also subject this
company and, in some cases, an individual to substantial civil penalties. The company’s policy
on sexual harassment is part of its overall affirmative action efforts pursuant to federal and
state laws prohibiting discrimination based on age, race, color, religion, national origin, and
citizenship status, unfavorable discharge from the military, marital status, disability and gender.
Specifically, sexual harassment is prohibited by Title VII of the Civil Rights Act of 1964 and the
Illinois Human Rights Act. Each employee of this company must refrain from sexual harassment
in the workplace. No employee - male or female - should be subjected to unsolicited or
unwelcome sexual overtures or conduct in the workplace. Furthermore, it is the responsibility
of all supervisors and managers to make sure that the work environment is free from sexual
harassment. All forms of discrimination and conduct which can be considered harassing,
coercive or disruptive, or which create a hostile or offensive environment must be eliminated.
Instances of sexual harassment must be investigated in a prompt and effective manner. All
employees of this company, particularly those in a supervisory or management capacity, are
expected to become familiar with the contents of this policy and to abide by the requirements
it establishes.
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Appendix C
Accident/Incident Report Form
Employee’s Report of Injury Form Instructions: Employees shall use this form to report all work
related injuries, illnesses, or “near miss” events (which could have caused an injury or illness) –
no matter how minor. This helps us to identify and correct hazards before they cause serious
injuries. This form shall be completed by employees as soon as possible and given to a
supervisor for further action. I am reporting a work related: ‰Injury ‰Illness ‰Near miss Your
Name: Job title: Supervisor: Have you told your supervisor about this injury/near miss? ‰Yes ‰
No Date of injury/near miss: Time of injury/near miss: Names of witnesses (if any): Where,
exactly, did it happen? What were you doing at the time? Describe step by step what led up to
the injury/near miss. (Continue on the back if necessary): What could have been done to
prevent this injury/near miss? What parts of your body were injured? If a near miss, how could
you have been hurt? Did you see a doctor about this injury/illness? ‰Yes ‰No If yes, whom did
you see? Doctor’s phone number: Date: Time: Has this part of your body been injured before? ‰
Yes ‰No If yes, when? Supervisor: Your signature: Date: 2 Supervisor’s Accident Investigation
Form Name of Injured Person _________________________________________________ Date
of Birth _________________ Telephone Number ____________________ Address
______________________________________________________________ City
_____________________________ State_______ Zip _____________ (Circle one) Male Female
What part of the body was injured? Describe in detail.
________________________________________
______________________________________________________________________________
_______ what was the nature of the injury? Describe in detail.
_________________________________________
______________________________________________________________________________
______________________________________________________________________________
Describe fully how the accident happened? What was employee doing prior to the event? What
equipment, tools being using?
____________________________________________________________
______________________________________________________________________________
_______
______________________________________________________________________________
_______ Names of all witnesses: ______________________________________
_______________________________________ ______________________________________
_______________________________________ Date of Event ______________________ Time
of Event _________________________________ Exact location of event:
_________________________________________________________________ What caused
the event? _________________________________________________________________
______________________________________________________________________________
_______
______________________________________________________________________________
_______ were safety regulations in place and used? If not, what was wrong?
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______________________________
______________________________________________________________________________
_______ Employee went to doctor/hospital? Doctor’s Name
___________________________________________ Hospital Name
__________________________________________ Recommended preventive action to take in
the future to prevent reoccurrence.
______________________________________________________________________________
______
______________________________________________________________________________
______
______________________________________________________________________________
______ ______________________ ___________ Supervisor Signature Date 3 Incident
Investigation Report Instructions: Complete this form as soon as possible after an incident that
results in serious injury or illness. (Optional: Use to investigate a minor injury or near miss that
could have resulted in a serious injury or illness.) This is a report of a: ‰Death ‰Lost Time ‰Dr.
Visit Only ‰First Aid Only ‰Near Miss Date of incident: This report is made by: ‰Employee ‰
Supervisor ‰Team ‰Other_________ Step 1: Injured employee (complete this part for each
injured employee) Name: Sex: ‰Male ‰Female Age: Department: Job title at time of incident:
This employee works: ‰Regular full time ‰Regular part time ‰Seasonal ‰Temporary Months
with this employer Months doing this job: Part of body affected: (shade all that apply) Nature of
injury: (most serious one) ‰Abrasion, scrapes ‰Amputation ‰Broken bone ‰Bruise ‰Burn
(heat) ‰Burn (chemical) ‰Concussion (to the head) ‰Crushing Injury ‰Cut, laceration,
puncture ‰Hernia ‰Illness ‰Sprain, strain ‰Damage to a body system: ‰Other ___________
Step 2: Describe the incident Exact location of the incident: Exact time: What part of
employee’s workday? ‰Entering or leaving work ‰Doing normal work activities ‰During meal
period ‰During break ‰Working overtime ‰Other___________________ Names of witnesses
(if any): 4 Number of attachments: Written witness statements: Photographs: Maps / drawings:
What personal protective equipment was being used (if any)? Describe, step-by-step the events
that led up to the injury. Include names of any machines, parts, objects, tools, materials and
other important details. Description continued on attached sheets: ‰Step 3: Why did the
incident happen? Unsafe workplace conditions: (Check all that apply) ‰Inadequate guard ‰
Unguarded hazard ‰Safety device is defective ‰Tool or equipment defective ‰Workstation
layout is hazardous ‰Unsafe lighting ‰Unsafe ventilation ‰Lack of needed personal protective
equipment ‰Lack of appropriate equipment / tools ‰Unsafe clothing ‰No training or
insufficient training ‰Other: _____________________________ Unsafe acts by people: (Check
all that apply) ‰Operating without permission ‰Operating at unsafe speed ‰Servicing
equipment that has power to it ‰Making a safety device inoperative ‰Using defective
equipment ‰Using equipment in an unapproved way ‰Unsafe lifting ‰Taking an unsafe
position or posture ‰Distraction, teasing, horseplay ‰Failure to wear personal protective
equipment ‰Failure to use the available equipment / tools ‰Other:
__________________________________ Why did the unsafe conditions exist? Why did the
unsafe acts occur? Is there a reward (such as “the job can be done more quickly” or “the
product is less likely to be damaged” that may have encouraged the unsafe conditions or acts?
‰Yes ‰No If yes, describe: Were the unsafe acts or conditions reported prior to the incident? ‰
23. 23SCSA RiskAnalysis
Yes ‰No Have there been similar incidents or near misses prior to this one? ‰Yes ‰No 5 Step 4:
How can future incidents be prevented? What changes do you suggest to prevent this
incident/near miss from happening again? ‰Stop this activity ‰Guard the hazard ‰Train the
employee(s) ‰Train the supervisor(s) ‰Redesign task steps ‰Redesign work station ‰Write a
new policy/rule ‰Enforce existing policy ‰Routinely inspect for the hazard ‰Personal
Protective Equipment ‰Other: ____________________ What should be (or has been) done to
carry out the suggestion(s) checked above? Description continued on attached sheets: ‰Step 5:
Who completed and reviewed this form? (Please Print) Written by: Department: Title: Date:
Names of investigation team members: Reviewed by: Title: Date:
32. 32SCSA RiskAnalysis
References
1. Employee’s Report of Injury Form. (n.d.). Retrieved April 30, 2015.
2. Groebe, L. (n.d.). Gilani - Forney Sports Center - Release & Waiver (Assumption.
Retrieved April 30, 2015.
3. J. (n.d.). SEXUAL HARASSMENT POLICY STATEMENT. Retrieved April 30, 2015.
4. Justice, U. D. (n.d.). ADA Readily Achievable Barrier Removal Checklist for Existing
Facilities. Retrieved April 30, 2015.
5. Sport facility management: Organizing events and mitigating risks. Morgantown, WV:
Fitness Information Technology. (n.d.). Retrieved April 30, 2015