Accident Investigation Report

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Identification of the Incident

• Type of injury

  First aid

  Lost Time

  Fatality

• Incident recognized by

• Date of Incident

  Date

• Date Reported

  Date

• Any witnesses

• Location of Incident (Department, Machine No., etc)

Description of Incident

• Give specific details of Incident

Description of Injury and Treatment given

• Give specific details of Injury

• Was first aid required

  Yes

  No

• Was Medical Attention Required

  Yes

  No

• What type of initial treatment received and by whom

The Cause and Remedy

• What caused the incident

• Was an unsafe act committed or did unsafe conditions exist. ( explain in detail)

• Could incident have been prevented. ( explain in detail)

Reviewed by

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