• Document No.

  • Audit Title (initials of injured associate-mm-dd-yy)

  • Date and Time of Incident

  • Accident Incident Investigation Form Prepared by (full name, employee ID, position)

  • Date and Time Accident Incident Investigation Form was initiated

  • Area / Location of Accident

PERSONAL INFORMATION (injured employee)

  • Employees full name

  • Date of birth

  • Enter date and time of injury or accident

  • Take picture of 1.) Incident Report. 2.) Page 1 FDC Incident/ Investigation Report

Manager / Safety Team Investigation

  • Employment Category

  • Length of employment

  • Time in occupation at time of incident

  • Type of operation

  • Was this operation a regular part of employees job?

  • Time associate reported to work on date of incident?

  • Type of injury

  • Does equipment have lockable disconnect?

  • Name and title of person who assigned task/job


  • How long since a supervisor was in area of incident and who?

  • We're there any witnesses to the incident? What are the witnesses names?

Accident Sequence - describe in reverse order the occurrence of events preceding the injury

  • Injury Event / Accident Event

  • Describe the preceding events that led up to the injury or accident

  • Preceding Events
  • Was PPE required for this task?

  • What PPE was required and in use at time of incident

  • Provided?

  • Trained on proper use?

  • Proper use of PPE?

  • PPE use enforced by manager and supervisor?

  • Was equipment adequately guarded? If no describe deficiency

  • Has employee received training prior to job assignment?

  • Who performed training?

  • What was the duration of the training?

  • Was training adequate?

  • Was lockout necessary?

  • Was employee trained?

  • Was training adequate?

  • Was lock provided?

  • Was written procedure required?

  • Was procedure provided to follow?


  • Where were you at the time of the incident?

  • What time did the incident occur?

  • What were you doing at the time of the incident

  • What injury resulted from the incident?

  • Was there any ergonomic (strain/sprain) from the incident?

  • We're any Pre-existing conditions with the injury area?

  • Did you have to

  • If moving a object what was the estimated weight?

  • Did you ask for help with lifting?

  • Demonstrate how the task was performed

  • Could you have done anything different to prevent the injury?

  • Was there a laceration incident

  • What type of equipment or tool was used?

  • We're there any know issues with the equipment/tool not functioning properly?

  • Demonstrate how the task was performed

  • Could you have done anything different to prevent the injury?

  • Was there a trauma incident?

  • Did a trip, slip, bump, falling object cause the incident?

  • Was a ladder involved?

  • What type?

  • Where were your feet placed on the ladder?

  • Was the ladder inspected as part of the Fall Protection Program?

  • We're there any safety restraints in place?

  • Demonstrate how the task was performed

  • How could this incident been prevented?

  • How often do you perform this task?

  • Are there any specific PPE requirements for the task and were they used?

  • Was training provided for this task?

  • Were any safety mechanisms by-passed?

  • After your involvement with this incident, is there any insight you could share or preventative actions you would recommend?


  • Enter conclusions


  • Enter all correct preventative actions that will be implemented


  • Take pictures of injury/accident including body part(s), location, equipment, tools, etc.

  • Add drawing


  • Name / Signature of Employee (required)

  • Name / Signature of Supervisor / Lead

  • Name / Signature of Department Manager (required)

  • Name / Signature of Safety Team Lead (required)

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.