Information
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Document No.
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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
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Date of this report
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Name of injured
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Date and time of accident
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Names of investigation team (include title and contact number)
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Investigator #1
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Investigator #2
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Investigator #3
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Investigator #4
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Witnesses to the accident (include contact information for follow-up)
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Witness #1
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Witness #2
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Witness #3
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Witness #4
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Location of accident
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Describe the accident
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List injuries (lacerations,bruises, burns, parts of body affected)
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Was employee seen by a doctor?
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If yes to above question, please list doctor
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Was employee admitted to a hospital?
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If yes to above question, please list hospital admitted to
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Enter date employee is expected to be back at work. If no lost time, enter the date of the accident
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Was blood involved with the accident?
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Do you think anyone may have had a blood borne exposure?
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Weather condition at time of accident (weatherunderground.com)
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Sky (clear, rainy, etc.)
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Temperature
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Wind speed
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Wind direction
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Factors that may have caused the accident
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Factor #1
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Factor #2
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Factor #3
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Factor #4
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Evidence gathered at the scene?
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List and identify all evidence
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Photographs taken at the scene?
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Add media
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Rough sketch and measurements of accident #1
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Rough sketch and measurements of accident #2
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Rough sketch and measurements of accident #3
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Rough sketch and measurements of accident #4
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Was there a safety rule or policy that could have prevented this accident?
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If yes to above question, list the rules or policies
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Signature and name of investigator #1
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Signature and name of investigator #2
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Signature and name of investigator #3
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Signature and name of investigator #4
