Accident Investigation Report 1765

• Plant

• Audit Title

• Conducted on

  Date

• Prepared by

• Supervisor in Charge

Accident/Incident Details

• Employee Name

• Date and time of injury;

  Date

• Department

• Machine Accident Happened (please be specific)

• What is Severity of the Incident?

• Severity:

  Near Miss

  First Aid

  Recordable

  Lost Time

  Fatality

• If Injured Give Details

• Part of Body injured:

• Picture of Injury if Applicable:

  Media

• What type of provider performed treatment?

  First Aid

  Hospital

  Chiropractor

  Family Physician

• Cause or Causes of the incident:

• Picture of Contributing Causes:

  Media

Supervision details

• Was Supervisor Notified?

  Yes

  No

  N/A
Tap to enter information

• Name of Supervisor?

Injured Party statement

• Name & Signature of the injured party

  Sign

Witness statements

• Was there a Witness?

  Yes

  No

  N/A
Tap to enter information

• How Many?

  1

  2

  3
Tap to enter information

• Witness 1 Statement:

• Witness 1 Signature

  Sign
Tap to enter information

• Witness 1 Statement:

• Witness 1 Signature

  Sign

• Witness 2 Statement:

• Witness 2 Signature

  Sign
Tap to enter information

• Witness 1 Statement:

• Witness 1 Signature

  Sign

• Witness 2 Statement:

• Witness 2 Signature

  Sign

• Witness 3 Statement:

• Witness 3 Signature

  Sign

Corrective Actions

Action: Short Term

• What was the immediate action taken to correct the issue (how was this done):

• Who was the responsible party for correcting the issue:

Action: Long Term

• What is the long term action needed to correct the issue:

• Who was the responsible party for correcting the issue:

Investigation Conclusions

Person Completing Form (please sign below)

• Is the above report a true reflection of the Accident / Incident

  Sign

Supervisor in Charge (please sign below)

• Is the above report a true reflection of the Accident / Incident

  Sign