Livestock Handling Injury Incident Report Form

Purpose

This form documents injuries, near-misses, and safety incidents that occur during livestock handling operations. Thorough documentation helps identify patterns, improve safety procedures, and meet legal requirements for record-keeping. Complete this form for ANY injury requiring more than basic first aid, and for significant near-misses.

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SECTION 1: BASIC INFORMATION

Incident Identification

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Location Information

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SECTION 2: INJURED PERSON INFORMATION

• [ ] Family Member
• [ ] Hired Employee
• [ ] Temporary/Seasonal Worker
• [ ] Volunteer
• [ ] Visitor
• [ ] Other: _________________________

SECTION 3: INCIDENT DESCRIPTION

What Happened

_________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________

Animal Involved

• [ ] Cattle
• [ ] Horse
• [ ] Hog
• [ ] Sheep/Goat
• [ ] Other: _________________________
• [ ] Cow
• [ ] Calf
• [ ] Heifer
• [ ] Steer
• [ ] Mare
• [ ] Stallion
• [ ] Gelding
• [ ] Foal
• [ ] Sow
• [ ] Boar
• [ ] Other: _________________________
• [ ] Charged
• [ ] Crushed/Pinned
• [ ] Stepped on
• [ ] Head butted
• [ ] Bit
• [ ] Knocked down
• [ ] Threw (horse)
• [ ] Other: _________________________
• [ ] Agitated before incident
• [ ] Unknown temperament
• [ ] Known problem animal
• [ ] Newly acquired
• [ ] Protective of young

Activity at Time of Incident

• [ ] Sorting/moving cattle
• [ ] Loading/unloading
• [ ] Feeding
• [ ] Treating/medicating
• [ ] Riding
• [ ] Leading/handling
• [ ] Cleaning/maintenance
• [ ] Other: _________________________

Facility and Equipment

• [ ] Working alley
• [ ] Crowding pen
• [ ] Open pen
• [ ] Pasture
• [ ] Loading chute
• [ ] Barn/building
• [ ] Other: _________________________
• [ ] Head gate
• [ ] Panel/gate
• [ ] Trailer
• [ ] ATV/UTV
• [ ] Tractor
• [ ] Horse tack
• [ ] Other: _________________________

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SECTION 4: INJURY INFORMATION

Nature of Injury

• [ ] Laceration/Cut
• [ ] Contusion/Bruise
• [ ] Sprain/Strain
• [ ] Crush injury
• [ ] Puncture
• [ ] Bite
• [ ] Concussion/Head injury
• [ ] Internal injury
• [ ] Burns
• [ ] Other: _________________________
• [ ] Neck
• [ ] Shoulder
• [ ] Arm
• [ ] Hand/Fingers
• [ ] Chest/Ribs
• [ ] Back
• [ ] Abdomen
• [ ] Hip/Pelvis
• [ ] Leg
• [ ] Knee
• [ ] Ankle/Foot
• [ ] Other: _________________________

Severity Assessment

• [ ] Moderate (medical attention, no lost work time)
• [ ] Serious (lost work time, no hospitalization)
• [ ] Severe (hospitalization required)
• [ ] Critical (life-threatening)
• [ ] Fatal

Medical Treatment

If yes, by whom: _________________________

What was done: _________________________________________

• Time arrived: _____________
• Agency: _________________________
• Transport destination: _________________________
• [ ] Urgent care
• [ ] Emergency room
• [ ] Hospital admission
• [ ] Specialist
• [ ] Other: _________________________

SECTION 5: CONTRIBUTING FACTORS

Environmental Conditions

• [ ] Hot (above 90°F)
• [ ] Cold (below 40°F)
• [ ] Wet/Raining
• [ ] Windy
• [ ] Dusty
• [ ] Dark/Low light
• [ ] Other: _________________________
• [ ] Wet/Muddy
• [ ] Icy
• [ ] Uneven
• [ ] Slippery (manure)
• [ ] Other: _________________________

Human Factors

• [ ] Rushing/Time pressure
• [ ] Lack of experience
• [ ] Lack of training
• [ ] Distraction
• [ ] Poor communication
• [ ] Not following procedures
• [ ] Physical limitation
• [ ] Working alone
• [ ] Other: _________________________
• Eye protection: Yes / No / N/A
• Hearing protection: Yes / No / N/A
• Gloves: Yes / No / N/A
• Other: Yes / No / N/A

Facility/Equipment Factors

• [ ] Inadequate escape routes
• [ ] Blocked escape route
• [ ] Poor lighting
• [ ] Poor facility design
• [ ] Damaged/worn equipment
• [ ] Missing safety equipment
• [ ] Other: _________________________

Animal Factors

• [ ] Pain or illness
• [ ] Unfamiliar animal
• [ ] Known aggressive animal
• [ ] Fear/Stress response
• [ ] No prior warning signs
• [ ] Other: _________________________

SECTION 6: WITNESSES

Witness 1

_________________________________________

Witness 2

_________________________________________

Witness 3

_________________________________________

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SECTION 7: IMMEDIATE RESPONSE

Actions Taken at Scene

• [ ] First aid provided
• [ ] 911 called
• [ ] Area secured
• [ ] Animal contained
• [ ] Equipment shut down
• [ ] Other workers notified
• [ ] Family notified
• [ ] Supervisor notified

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SECTION 8: CORRECTIVE ACTIONS

Short-Term Actions

_________________________________________ _________________________________________

Long-Term Recommendations

_________________________________________ _________________________________________

_________________________________________

_________________________________________

_________________________________________

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SECTION 9: FOLLOW-UP

Status Tracking

Return to Work

• [ ] Light duty
• [ ] Partial hours
• [ ] Different assignment

SECTION 10: SIGNATURES

Injured Person Statement

"I have reviewed this report and believe it to be accurate to the best of my knowledge."

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Supervisor/Manager Review

_________________________________________

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Safety Committee Review (if applicable)

_________________________________________

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SECTION 11: ATTACHMENTS

• [ ] Photos of equipment involved
• [ ] Photos of injuries (if appropriate and consented)
• [ ] Facility diagram/map
• [ ] Medical records/bills
• [ ] Witness written statements
• [ ] Equipment maintenance records
• [ ] Training records
• [ ] Other: _________________________

Distribution

• [ ] Copy to injured person
• [ ] Copy to personnel file
• [ ] Copy to safety records
• [ ] Copy to insurance carrier
• [ ] Copy to workers' compensation
• [ ] Other: _________________________

Confidentiality Notice

This report contains confidential information protected by privacy laws. Distribution should be limited to those with a legitimate need to know for safety, medical, insurance, or legal purposes.

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Retention

Maintain this record for a minimum of:

• 5 years for OSHA recordkeeping (if applicable)
• 7 years for general liability purposes
• Per your insurance carrier requirements
• Per your attorney's recommendation

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