Dorsey Trailer, LLC Accident Investigation Report

FOR OFFICE USE

• Document No.

• Conducted on

  Date
• Location
  Address

• Prepared by

DEMOGRAPHICS

• Date and time of accident:

  Date

• Date and time accident was reported:

  Date

• To whom was the accident reported?

• List all employees involved:

• Department:

• Supervisor's Name:

• Were there any witnesses?

  Yes

  No

• If yes, provide name(s).

PERSON(S) INVOLOVED

• Name:

• Birthday:

  Date

• Age:

• Sex:

  Male

  Female

• Job Title:

• Job Status:

  Full-time

  Part-time

  Temporary

  Seasonal

• Employee Disposition Status:

  Returned to Work

  Sent Home

  To Doctor

  To Emergency Room

PHYSICAL DAMAGES

• Property Damage:

  None

  Minor

  Serious

  Major

• Type:

  Trailer

  Tools & Equipment

  Building & Grounds

• Describe damage:

ACCIDENT INFORMATION

• Detailed description of accident: (Include environmental conditions)

• What could have potentially happened?

• What was the potential for severity?

  Minor

  Serious

  Major

• What is the probability of reoccurrance?

  Remote

  Improbable

  Probable

• Corrective Action Issued:

NATURE OF INJURY

• Classification:

  Select OSHA reportable First-Aid only Needs medical attention Near miss Lost time

  • OSHA reportable
  • First-Aid only
  • Needs medical attention
  • Near miss
  • Lost time

• Describe injury:

• Detail any first-aid or medical treatment administered:

VERIFYING OFFICIAL'S INFORMATION

• EHS Official's Name:

• EHS Official's Position:

• Signature:

  Sign

• Date & Time:

  Date