CWS Accident Investigation Report - vs- 2019

• Document No.

• Conducted on

  Date

• Prepared by

• Property name

• Location
  Address

• Property phone number

• Name

• Job title

• Supervisor

• Supervisor phone number

I. Background Information on Injured Person (if any)

• Name:

• Property:

• Job Title:

• Property Address:

• Add location
  Address

• Property Phone Number:

• Supervisor:

• Supervisor Phone / Extension:

II. Witnesses

• We're there any witnesses to the incident?

  Yes

  No

  N/A

• Witness #1 Name

• Phone number

• Witness #2 Name

• Phone number

III. Description of Accident / Near Miss:

• Description of Accident / Near Miss: (Describe sequence of events, including time date and location of incident. Attach any photos, drawings, or separate page if necessary)
  
  

• REQUIRED- Please take photos of incident area, items effecting accident, and any and all other items that may assist with the reporting of this record.
  
  

• Add media

  Media

IV. Factors

• Describe conditions or practices, if any, that may have led to the occurrence of this incident. Attach additional page / information if necessary)

• Add media

  Media

• Was this a preventable injury?

  yes

  no

• Was PPE required?

  yes

  no

• If yes, please list equipment
  
  
  

• Was it worn at time of incident?

  yes

  no

V. Corrective Actions

• In your opinion, what are reasonable actions or steps that could be taken to eliminate or reduce the likelihood of a recurrence? (Attach additional page or information if necessary)

• How could this injury have been a prevented? Choose the one overall appropriate area of concern that best describes the contributing cause to this preventable injury.

• Focus

  Select Staffing Work Work Load Lack of Attention

  • Staffing Work
  • Work Load
  • Lack of Attention

• Training

  Select New Employee Not following policy Not using proper PPE Not properly trained

  • New Employee
  • Not following policy
  • Not using proper PPE
  • Not properly trained

• Equipment Failure

  Faulty Equipment

  Old or worn equipment

VI. Emergency Services (if any)

• Were emergency services contacted?

  Yes

  No

  N/A

• Which service provider? (Police, EMS etc?)

• Describe medical attention provided.

• Investigation completed By:

• Date:

• Select date

  Date

• Investigators signature:

  Sign

• Community Director / Maintenance Director review and comments:

• CD / MD Signature:

  Sign

• Employee Signature

  Sign