Accident Investigation

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Accident Investigation

• Describe injury and parts of body affected

• What caused the accident

• What object/substance directly injured the employee

• State in the employees words where and how the accident occurred

• Pain from scale 1-10

• State in the employees own words description of pain/discomfort and location of injury

• What has been done to prevent a similar accident from happening again

• Give accurate description of nature and extend of injury and state your objective findings

• Employee signature

  Sign

• Preparers signature

  Sign

Witness Statement

• Witness name

• Address

• Occupation

• Telephone number

• Date and Time of injury

  Date

• Location where injury occurred

• Describe what you saw

• Who or what caused the accident/injury

• In your opinion what body parts were injured

• Was there anything that could have been done to prevent injury

• Did anything appear suspicious about the accident

• Witness signature

  Sign