Accident Investigation Report Template

• Department

• Full Name of Employee

• Age

• Conducted on (Date and Time)

  Date

• Full Name of Supervisor

General Information

• Capture photo of Identification

  Media

• Date and time of the incident

  Date
• Location of the incident
  Address

• Are there other people involved?

  No

  Yes

• Person/s involved? Click "Add"

  No

  Yes
Person

• Capture photo of Identification

  Media

• Phone Number

Accident Report

• What are the details of the accident?

• Capture photo evidence

  Media

• Why did the incident happen?

  Select Poorly maintained tools or equipment Poor housekeeping, slippery floor, or tripping hazards Unguarded equipment Crowded work condition Poor storage practices Failure to wear PPE Insufficient lighting or ventilation Cold or hot temperature Others

  • Poorly maintained tools or equipment
  • Poor housekeeping, slippery floor, or tripping hazards
  • Unguarded equipment
  • Crowded work condition
  • Poor storage practices
  • Failure to wear PPE
  • Insufficient lighting or ventilation
  • Cold or hot temperature
  • Others

• Please specify

• Incurred injuries

• Did the employee leave work?

  No

  Yes

• What are the consequences of the accident?

  Select Personal injury Property loss Lost income Medical expenses Lowered productivity Decreased employee moral Others

  • Personal injury
  • Property loss
  • Lost income
  • Medical expenses
  • Lowered productivity
  • Decreased employee moral
  • Others

• Please specify

Witness/es

• Are there any witness/es?

  Yes

  No

• Witness/es? Click "Add"

Witness

• Full Name

• Phone Number

• Statement

Completion

• Recommendations to avoid accident recurrence

• Supervisor Full Name and Signature

  Sign