DOA POST-ACCIDENT INTERVIEW REPORT

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Facts

• Date & time of accident

  Date

• Division(s) involved

  Select AOPS FAC TOPS LOPS FIN DIR GA CE PLN IS SEC ES

  • AOPS
  • FAC
  • TOPS
  • LOPS
  • FIN
  • DIR
  • GA
  • CE
  • PLN
  • IS
  • SEC
  • ES

• Section/shop

• Location of accident

• Photo

  Media

Employee

• Employee injured

• Title

• Badge number

• Type injury

  Select Cut Bruise Break Strain/sprain Scrape Exposure Smash Burn Amputation Other (explain below)

  • Cut
  • Bruise
  • Break
  • Strain/sprain
  • Scrape
  • Exposure
  • Smash
  • Burn
  • Amputation
  • Other (explain below)

• Explain "other"

• Body part

• Medical sought?

  Yes

  No

  N/A

• Employee's immediate supervisor

• Task in progress at time of injury

Property

• Property damaged

• Nature of damage

• Estimated cost to repair/replace

• Actual cost to repair/replace

• Photo

  Media

Accident

• Describe accident

• Source of accident

• Cause of accident

• Photo

  Media

• Sketch

  Drawing

Corrections

• Corrective action 1

• Corrective action 2

• Corrective action 3

Comments

• Employee comments

• Investigator comments

• Photo

  Media

Signatures

• Investigator

  Sign

• Date completed

  Date