ACCIDENT INVESTIGATION FORM

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location

PROCEDURE

• Preserve the accident scene and evidence. Make sure nothing is moved or changed unless hazards exist and it is safe to do so

• You may need to reconstruct the seen if it is safe to do to find out how the accident occurred and why

• Come up with a sequence of events, work conditions, and work procedures of the accident

• Find the root cause and complete a job hazard analysis along with how to control each hazard so it will not occur again. Train all employees on your findings and controls

ACCIDENT INVESTIGATION FORM

• Location of Accident

• Date & Time

  Date

• Weather Conditions

• Take photographs or sketches of scene. Inspect accident site before changes occur

  Media
Involved Employee

• Name

• Injured

  Yes

  No

  N/A

• Phone Number

Witnesses

• Name

• Phone Number

Incident Details

• What Happened

• Was injured employee properly trained on task?

  Yes

  No

  N/A

• When was last refresher?

  Date

• Why was the employee doing the task?

• Does the job have a Job Hazard Analysis (JHA)?

  Yes

  No

  N/A

• Was JHA being followed?

  Yes

  No

  N/A

• Why not?

• Was a Pre-task check list completed?

  Yes

  No

  N/A

• Why not?

• What work was being done when accident/incident occurred?

• What caused the accident/injury?

• What were the contributing factors to the accident/injury?

• Were there any safety violations that caused the accident/injury?

  Yes

  No

  N/A

• What are the Violations?

• Was the task a hurry up job?

  Yes

  No

  N/A

• Why?

Incident Findings

• Review the facts, conditions, work practices, and root cause of accident/injury

Corrective Actions

• Action

• Corrective Action Assigned to:

• Signature and Date

  Sign