Accident / Incident Report and Investigation

  • Department

  • Supervisor:

  • Location of Incident:

  • Type of incident:

  • Date of incident:

  • Date reported:

INJURY OR ILLNESS

  • Name of Injured:

  • Part of Body Injured:

  • Occupation:

  • Add media

Property Damage

Property Damage

  • Nature of Incident:

  • Nature of Damage:

  • Estimated Cost:

  • Object/Equipment/Substance Fault

  • Name of person(s) with most control:

  • Loss Severity Potential:

  • Add media

ENVIRONMENTAL RELEASE

ENVIRONMENTAL RELEASE

  • Nature of Incident:

  • Incident Cost if Applicable:

  • Person Reporting Incident:

  • Object / Equipment / Substance Fault:

  • Person With Most Control:

  • Probability of Occurance:

  • Add media

INCIDENT DESCRIPTION

INCIDENT DESCRIPTION:

  • Describe How the Event Occured:

Witness Statement

  • Describe What the Witness Saw:

  • Signature of Witness

CAUSES: What Actions and Conditions Caused the Event?

  • Unsafe Acts:

  • Unsafe Conditions

OTHER FACTORS

  • What specific Personal or Job Factors Caused or Could Cause This Event?

TYPE OF CONTACT

TYPE OF CONTACT

  • TYPE OF CONTACT

  • CONTACT WITH

SUPERVISOR'S CORRECTIVE ACTIONS:

  • What will be done to control the causes listed and prevent reoccurrence?

  • Signature of Supervisor:

  • Signature of Employee:

EHS REVIEW: To be completed by HR or Safety

  • I concur with Supervision's corrective or remedial actions.

  • After review I recommend the following corrective and/or remedial actions or add these comments:

  • EHS/ HR COMMENTS

  • Signature of Safety Representative

  • Incident Classification

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