ACCIDENT INVESTIGATION REPORT

• Accident Report No.

• Accident Investigation Report

• Accident Investigation Report

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Date and Time of Accident

  Date

I. COMPANY INFORMATION

• Name

• Address
  Address
• Accident Address (if different than above)
  Address

• Phone Number

• Fax Number

II . EMPLOYEE INFORMATION

• Name

• Address
  Address

• Phone Number

• Sex

• Age

• Department

• Job Title

• Employment Status

  Full Time

  Part Time

  Temporary

  Other

• Length of Employment

  Less than 1 month

  1 - 5 months

  6 months to 5 years

  More than 5 years

• Time in Occupation at Time of Accident

  Less than 1 month

  1 - 5 months

  6 months to 5 years

  More than 5 years

III. INJURY INFORMATION

• Person Reported To

• Date Reported

  Date

• Nature of Injury and Part of Body

• Employee's Specific Task and Activity at Time of Accident

• Employee was

  Working alone

  Working with assigned group

  Supervised

  Unsupervised

• Severity of Injury

  Select Fatality Lost work days - days away from work Days of restricted or job transfer Medical treatment First aid Other, specify

  • Fatality
  • Lost work days - days away from work
  • Days of restricted or job transfer
  • Medical treatment
  • First aid
  • Other, specify

• Name of Physician

• Name and Address of Hospital/Clinic

• Accident Report Numbers and Names of Others Injured

Information

• Report Number

• Name

IV. WITNESSES

• Are there any witnesses?

  Yes

  No
Witness

• Name

• Phone number

V. SCENE OF ACCIDENT

• Specific Location

• Describe How the Accident Occured

• Scene of Accident

  Media

• Diagram any Specific Location Factors that Contributed to the Accident

  Drawing

• Type of Equipment/Machinery Involved

• Equipment / Machinery Placed (if involved)

  Out of Service

  Repaired

  N/A

VI. ACCIDENT SEQUENCE

• Describe in order of occurrence the events leading to the incident and/or injury. Reconstruct the sequence of events that led to the accident.

Event
Accident Event
Injury Event

VII. CAUSAL FACTORS

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

VIII. 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.

Corrective Action

• Causal Factor

• Assignment Responsibilities

• Target Date for Completion

  Date

• Illustrate layout changes (if necessary)

  Drawing

IX. SUMMARY

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

• This Accident Investigation Report was prepared by:

  Sign

• Title

• Risk Management