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Audit

General Information
Capture photo of Identification
Date and time of the incident
Location of the incident

Are there other people involved?

Person/s involved? Click "Add"

Person
Capture photo of Identification

Phone Number

Accident Report

What are the details of the accident?

Capture photo evidence
Why did the incident happen?

Please specify

Incurred injuries

Did the employee leave work?

What are the consequences of the accident?

Please specify

Witness/es

Are there any witness/es?

Witness/es? Click "Add"

Witness

Full Name

Phone Number

Statement

Completion

Recommendations to avoid accident recurrence

Supervisor Full Name and Signature

Accident Investigation Report Template Checklist

Created by: SafetyCulture Staff | Industry: General | Downloads: 459

Accident investigation report template is used to determine the root cause of the accident to prevent future accidents. This template can be used by workplace supervisors to record accurate information. Follow the points below to utilize this template: 1. Gather the general information of the injured employee 2. Identify the details of the accident 3. Describe the consequences of the accident 4. Collect witness/es statements if applicable 5. Recommend actions to avoid accident reoccurrence

Signup for a free iAuditor account to download and edit this checklist. It will be added to your free account and you will be able to conduct inspections from your mobile device.

Download and edit this free checklist

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Audit

General Information
Capture photo of Identification
Date and time of the incident
Location of the incident

Are there other people involved?

Person/s involved? Click "Add"

Person
Capture photo of Identification

Phone Number

Accident Report

What are the details of the accident?

Capture photo evidence
Why did the incident happen?

Please specify

Incurred injuries

Did the employee leave work?

What are the consequences of the accident?

Please specify

Witness/es

Are there any witness/es?

Witness/es? Click "Add"

Witness

Full Name

Phone Number

Statement

Completion

Recommendations to avoid accident recurrence

Supervisor Full Name and Signature