Boys & Girls Clubs of Kern County Accident Investigation Report

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Incident Identification Information

• Type of Injury:

  First Aid

  Lost Time

  Medical Emergency

• Who was involved/Injured in the Incident?

• Date and Time Incident Occured:

  Date

• Date and Time Incident Was Reported:

  Date

• Were there any witnesses to the incident?

  Yes

  No

• If yes, who?

• Location of Incident (area at the site):

• Describe the incident in detail:

Injury and Treatment Identification Information

• Was first aid required?

  Yes

  No

• Was emergency medical attention required?

  Yes

  No

• Describe the injury in detail:

• What type on initial treatment was administered, and who administered it?

Cause and Remedy Identification Information

• Has this or a similar incident occurred at this site before?

  Yes

  No

• If yes, with what frequency?

  Frequent

  Occasional

  Rare

• Was company policy violated to create this incident?

  Yes

  No

• If yes, what policy?

• Was there an unsafe act or unsafe condition involved in this incident?

  Yes

  No

• If yes, explain in detail.

• In hind sight, could this incident have been avoided?

  Yes

  No

• If yes, explain in detail.

• Describe what can be done to prevent this or similar incidents in the future:

Signatures

• Who created this report?

  Sign