Accident Investigation Report - Rev 1

• Accident Investigation Number:

• Accident Date and Time:

  Date

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

Company Information

• Name:

• Address:
  Address
• Accident Address ( if Different than above ):
  Address

• Phone #

• Investigator:

• Investigator Phone #

Employee Information:

• Name:

• Home Address:
  Address

• Phone #

• National Insurance Number #

• Age:

• Sex:

• Department:

• Job Title:

• Employee Status:

  Select Full Time Part Time Self Employed Agency Other

  • Full Time
  • Part Time
  • Self Employed
  • Agency
  • Other

• Length of Employment:

  Select Less Than 1 Month 1 - 5 Months 6 Months to 5 Years More Than 5 Years

  • Less Than 1 Month
  • 1 - 5 Months
  • 6 Months to 5 Years
  • More Than 5 Years

• Time in Occupation at Work at Time of Accident:

  Select < 1 hour < 3 hours < 5 hours < 8 hours > 8 hours

  • < 1 hour
  • < 3 hours
  • < 5 hours
  • < 8 hours
  • > 8 hours

Injury Information:

• Person Reported to:

• Date and Time Reported:

  Date

• Nature of Injury and Part of Body Affected:

• Indicate Location of Injury on Body

  Drawing

• Specific Task and Activity at the Time of Accident:

• How was the Injured Person Working

  Select Working Alone Working with assigned group Supervised Not Supervised

  • Working Alone
  • Working with assigned group
  • Supervised
  • Not Supervised

• Severity of Injury:

  Select Fatality - RIDDOR Specified injury - RIDDOR Lost days away from work > 7 - RIDDOR Days of restricted activity or job transfer Hospital treatment First aid

  • Fatality - RIDDOR
  • Specified injury - RIDDOR
  • Lost days away from work > 7 - RIDDOR
  • Days of restricted activity or job transfer
  • Hospital treatment
  • First aid

• Names of any Other Persons Injured, and Associated Accident Report Numbers:

• Name of Doctor that Reviewed Injury:

• Name and Address of Hospital / Clinic?

Witnesses:

• Name & Phone #

• Name & Phone #

• Name & Phone #

• Name & Phone #

• Name & Phone #

Scene of Accident Information:

• Specific Location:
  Address

• Describe How the Accident Occurred:

• Diagram any Specific Location Factors That Contributed to the Accident:

  Drawing

• Type of Equipment / Machinery Involved:

• Equipment / Machinery Has been:

  Select Out of Service Repaired

  • Out of Service
  • Repaired

Accident Sequence: Describe in order of occurrence the events leading to the accident and/or injury. Reconstruct the sequence of events that led to the accident.

• Event# 1

• Event# 2

• Accident Event:

• Injury Event:

Causal Factors:

• Describe events and conditions that contributed to the accident. Include information on worker, machinery and equipment, environment and management.

Corrective Actions: Identify the factors listed above that can be corrected to prevent a reoccurrence of this type of accident. Indicate the person responsible for making the change and project a target date for completion of the task. Use the diagram grid below to illustrate layout changes.

• Causal Factor and Corrective Action

• Assignment Responsibilities:

• Target Date for Completion:

• Diagram:

  Drawing

• Pictures:

  Media

• Summary: Include comments that would promote a safe workplace environment and reduce an accidents potential in the future based on review of the causal Factors and implementation of Corrective Actions.

Confirmation by Individual that the Contents of this Report are to the best of their Knowledge Correct:

• Signature:

  Sign

• Date:

  Date

• Title:

• Title / Position:

This Accident Investigation Report was prepared by:

• Signature:

  Sign

• Date:

  Date

• Title:

• Department:

Approved by ( If Corrective action is required.)

• Signature:

  Sign

• Date:

  Date

• Title: