Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
Accident Investigation Report:
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Accident Report Number:
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Accident Date & Time:
Company Information
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Name:
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Address:
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Accident Address ( if Different than above ):
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Phone #
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Investigator:
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Investigator Phone #
Employee Information:
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Name:
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Home Address:
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Phone #
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Social Security #
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Age:
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Sex:
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Department:
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Job Title:
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Employee Status:
- Full Time
- Part Time
- Temporary
- Other
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Length of Employment:
- Less Than 1 Month
- 1 - 5 Months
- 6 Months to 5 Years
- More Than 5 Years
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Time in Occupation at time of accident:
- Less Than 1 Month
- 1 - 5 Months
- 6 Months to 5 Years
- More Than 5 Years
Injury Information:
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Person Reported to:
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Date & Time Reported:
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Nature of Injury and Part of Body Affected:
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Employees Specific Task and Activity at the Time of Accident:
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Was the Employee Working:
- Working Alone
- Working with assigned group
- Supervised
- Not Supervised
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Severity of Injury:
- Fatality
- Lost Days-Days Away from work
- Days of Restricted Activity or job Transfer
- Medical Treatment
- First Aid
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Accident Report Numbers and Names of Others Injured:
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Name of Physicians:
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Name and Address of Hospital / Clinic:
Witnesses:
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Name & Phone #
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Name & Phone #
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Name & Phone #
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Name & Phone #
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Name & Phone #
Scene of Accident Information:
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Specific Location:
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Describe How the Accident Occurred:
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Diagram any Specific Location Factors That Contributed to the Accident:
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Type of Equipment / Machinery Involved:
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Equipment / Machinery Has been:
- Out of Service
- Repaired
Accident Sequence: Describe in order of occurrence the events leading to the accident and/or injury. Reconstruct the sequence of events that led to the accident.
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Event# 1
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Event# 2
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Accident Event:
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Injury Event:
Causal Factors:
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Describe events and conditions that contributed to the accident. Include information on worker, machinery and equipment, environment and management.
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. Use the diagram grid below to illustrate layout changes.
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Causal Factor:
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Assignment Responsibilities:
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Target Date for Completion:
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Diagram:
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Pictures:
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Summary: Include comments that would promote a safe workplace environment and reduce an accidents potential in the future based on review of the causal Factors and implementation of Corrective Actions.
This Accident Investigation Report was prepared by:
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Signature:
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Date:
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Title:
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Department:
Approved by ( If Corrective action is required.)
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Signature:
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Date:
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Title: