Accident/Incident Investigation

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Company Name

Project Number

Date and Time of Incident

• Select date

  Date

Date Accident/Incident Reported

Person Injured

• Yes

  No

  N/A

Name

Job Title

Part of Body Injured

Type of Accident

Equipment, Object, or Substance Causing Injury

Property Damage

• Yes

  No

  N/A

Estimated Repair Cost

Person in Control

Description of Damage

Equipment, Object, or Substance Causing Damage

Describe How the Event Occured

What were the Contributing Factors

What were the Hazardous Conditions

Could This Accident Recur

• Select Often Occasionally Rare

  • Often
  • Occasionally
  • Rare

Would a recurrence be

• Select Very Severe Serious Minor

  • Very Severe
  • Serious
  • Minor

Action to be Taken

Action Already Taken

Person Doing the Investigation

• Add signature

  Sign