DOA ACCIDENT INVESTIGATION REPORT

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Date and time of accident

  Date

• Location of accident

• Classification

  No injury

  First aid

  Medical

  Lost time

  Fatality

• Injured person

• Job title

• Badge/PRNR

• Supervisor

• Nature of injury

  Select Cut Bruise Burn (heat) Fracture Exposure Sprain/strain Scrape Crush Fatality

  • Cut
  • Bruise
  • Burn (heat)
  • Fracture
  • Exposure
  • Sprain/strain
  • Scrape
  • Crush
  • Fatality

• Body part(s) injured

• Was medical assistance given at site?

• Place where injuries were ltreated.

• Did injured return to work?

  Yes

  No

  N/A

• Is this:

  New injury

  Re-injury

  Exacerbation of previous injury

• Date of previous injury

  Date

• Had employee received training about how to avoid this accident?

  Yes

  No

  N/A

• When?

  Date

• What PPE was required for this task?

  Select Safety glasses Goggles Face shield Impermeable gloves Leather gloves Hearing protection Hard hat Steel toe shoe Non-slip shoe Personal fall protection Apron Rain gear Hi-vis vest Rated PPE Respirator Other

  • Safety glasses
  • Goggles
  • Face shield
  • Impermeable gloves
  • Leather gloves
  • Hearing protection
  • Hard hat
  • Steel toe shoe
  • Non-slip shoe
  • Personal fall protection
  • Apron
  • Rain gear
  • Hi-vis vest
  • Rated PPE
  • Respirator
  • Other

• Was employee wearing it?

  Yes

  No

  N/A

ACCIDENT

• Task being performed at time of accident

• Describe the accident

• Property damaged?

  Yes

  No

• Nature of damage

• Owner of damaged property

• Anticipated cost to repair/replace

• Photo of damage

  Media

• Photo of damage

  Media

• Name of witness

• Witness statement

• Name of witness

• Witness statement

• Name of witness

• Witness statement

REMEDY

• What could have been done to prevent this accident?

• Describe immediate steps taken to prevent further injuries or damage

• Describe plan to prevent similar accidents?

SIGNATURES

• Investigator name & signature

  Sign

• Select date

  Date

• COMMENTS