Information
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Audit Title
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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
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Personnel
Investigation Report
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Company (Select Option)
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Date and Time of Accident
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Exact Location of Accident
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Employee Name
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SSN#
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Job Title
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Date Hired (mm/dd/year)
General Information
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Is this the employees first accident?
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Where was accident located?
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Job Name and Number
Description of the Accident
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Please describe what happened, in detail.
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Photo of accident area. Please provide as many as needed.
Accidents Conditions Involved
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Employee Job Description
- Administrative / Office
- Sales
- Fabrication / Welding Shop
- Mechanical
- Controls / Troubleshooting
- Maintenance
- Installation
- Fire Protection
- Plumbing
- Piping
- Sheet Metal
- Electrical
- Engineering
- Construction
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Hazardous Condition
- Improperly or Inadequately Guarded
- Unguarded
- Defective Tools
- Unsafe Design or Construction
- Improper Lighting
- Improper Ventilation
- Poor Housekeeping
- Congested Area
- No Unsafe Condition
- Other (specify below)
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Please describe if "Other"
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Severity of Treatment
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Was injured employee Hospitalized?
Body Part Injured
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Eye(s)
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Arm(s)
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Elbow
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Wrist
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Hand
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Buttocks
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Leg(s)
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Foot
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Knee
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Ankle
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Back
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Lungs / Throat / Mouth
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Chest / Ribs
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Abdomen
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Groin / Genitals
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Head / Neck
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Face
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Finger(s)
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Toe(s)
Unsafe Act & Other Contributing Factors
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Operating without Authority
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Unsafe Carrying / Lifting
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Taking Unsafe Position
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Failure to use PPE or improper use of PPE
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Failure to Secure Equipment
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Equipment Failure
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Poor or Inadequate Housekeeping
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Operating at Unsafe Speed or Beyond Capacity
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Congested Area
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Accident Caused by Another Employee
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Other (Specify)
Nature of Injury
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Foreign Object
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Cut
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Bruise / Contrusion
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Sprain / Strain
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Fracture
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Burn (Chemical)
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Burn (Thermal)
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Chemical Irritation
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Amputation
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Puncture Wound
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Hernia
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Dermatitis
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Smashed / Pinched
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Abrasion
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Infection
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Secondary infection
Accident Type
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Struck By / Against
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Caught In / Out / Between
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Fall (Same Level)
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Fall (Different Level) Height:
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Slip / Trip
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Vehicle Accident
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Contact with Temperature Extremes
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Repetitious Trauma
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Over Exertion
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Chemical Exposure
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Skin
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Inhalation
Protective Equipment
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Required but NOT in Use
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Required and IN Use
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Not Required (May have reduced injury)
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Not Required (would NOT have effected injury)
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Specify Protective Equipment in Use
Actions to Prevent Accident / Incident Re-OCCURANCE
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Restriction of Person(s) Involved
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Reprimand of Person(s)Involved
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Discipline of Person(s) Involved
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Action to Improve Inspection or Monitoring
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Action to Improve Construction
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Investigate Better Method
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Action to Improve Clean Up
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Request Job Safety Analysis to be Done
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Equipment Replacement or Repair
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Action to Improve Design
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Installation of Guard or Safety Device
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Request Pre-Job Instructions
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Correction of Unnecessary Congestion
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Improve PPE
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Inform Other Supervision
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Request Safety Observation
Root Cause(s)
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List any and ALL Root Causes
Indirect Cause(s)
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List any and ALL Indirect Causes
Recommended Corrective Action(s)
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ALL above listed items MUST be explained HOW reoccurrence will be prevented
Sign Off
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Individual assigned responsibility for carrying out measures for preventing reoccurrence.
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Date Corrective Action(s) to be completed
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Project Manager
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Safety Representative