Accident Investigation Report

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

COMPANY INFORMATION

• Co-Alliance Cooperative, Inc.

• 770 N. High School Road, Indianapolis, IN 46214

• Accident Address:
  Address

• Investigator Name

• Investigator Phone Number

EMPLOYEE(S) Information

• Repeat this section for multiple employees if applicable.

• Employee Name

• Sex

• Age

• Home Address

• Home Telephone Number

• Employee Telephone Number

• Department

• Job Title

• Employment Status

• Length of Employment

• Length of employment: Less than one month; 1 to 5 months; 6 months to 5 years; More than five years.

• Shift

• Hours Per Week

• Supervisor Name

• Supervisor Phone #

INJURY INFORMATION

• Person Reported To

• Date Reported

• Illness/Injury Type

• Body Part or System

• Source of Injury/Illness

• Accident Event/Exposure

• Employee's Specific Task at Time of Accident

• Day of Week

• Select One:

• Working Alone

• Working with Assigned Group

• Supervised

• Not Supervised

• SEVERITY OF INJURY

• Fatality

• Lost Work Days

• How many days?

• Restricted Activity/Job Transfer

• How many days?

• Medical Treatment

• First Aid

• Near Miss

• Other

• Specify

• ACCIDENT REPORT NUMBERS AND NAMES OF OTHERS INJURED.

• Name of Physician

• Name and address of hospital/clinic?

• Date of Treatment

• Time of Treatment

WITNESSES

• Name

• Telephone Number

SCENE OF ACCIDENT INFORMATION

• Specific Location
  Address

• Describe how the Accident Occured.

• Diagram of any specific Location factors that contributed to the accident.

  Media

• Describe any type of machinery/equipment involved.

• Make and Model

• Was the equipment up to date prior to the accident?

  Yes

  No

  N/A

• Was the equipment placed out of service or repaired?

  Yes

  No

  N/A

ACCIDENT SEQUENCE

• Event #1

• Event #2

• Event #3

• Event #4

• Accident Event

• Injury/Illness Event

CAUSES

• What was the cause of the accident? (see notes below).

• Describe events and conditions that contributed to the accident. Include information on site condititoins, the facilty, equipment, chemicals and stock materials, design, layout, location, changes, inspection, monitoring, hazard analysis, maintenance, hazard correction, work procedures and practices, communication, reporting, training, employee issues, management issues, natural disasters, weather conditions/events, and/or criminal/terrorist activity.

CORRECTIVE ACTIONS

• Identify the causes listed above that can be corrected to prevent a reoccurrence of this type of accident. Indicate the corrective action for each of these causes. Indicate the person responsible for making the change and project a target date for completion of the task. NOTE: A yes answer on "Corrective Action" will require a corrective action to be completed.

• Cause

• Corrective Action?

  Yes

  No

  N/A

• Add additional photos if needed.

  Media

SUMMARY

• Include comments that would promote a safe workplace environment and reduce an accident's potential in the future based on the review of the causes and implementation of corrective actions.

• Type your summary here.

SIGNATURE

• Name

• Title

• Department

• Signature

  Sign

• Date

  Date