Injury Investigation Form

Personnel

Employee ID#:

Dept/Division:

Job Position:

Date of Accident:

Employee Name:

Time of Accident (AM, PM):

Location:

Type of Injury:

Part of Body Injured:

Employee's Supervisor:

Detail Description of Accident:

Eye witness:

Environmental Conditions that may have contributed to the accident (weather, housekeeping, noise, light, etc.):

Underlying factors contributing to accident (not wearing PPE, faulty equipment, lack of training, non-attentive, etc.):

Corrective Actions to be taken (provide(d) training/tools, repair/replace, job procedures, work order, etc.):

Investigator's Name:

Safety Coordinator/Safety Designee:

Director/Asst. Director: