JCC Accident Investigation Form

• Jobsite name/number

• Jobsite address:

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel on site

• Injured Person

Type of incident:

• Illness

  Yes

  No

  N/A

• Injury

  Yes

  No

  N/A

• Fire/Explosion

  Yes

  No

  N/A

• Vehicle Accident

  Yes

  No

  N/A

• Property Damage

  Yes

  No

  N/A

• Unexpected Exposure

  Yes

  No

  N/A

• Health and Safety Infraction

  Yes

  No

  N/A

• Other: Describe:

  Yes

  No

  N/A

• Tap to enter information

What was employee doing"

• Tap to enter information

What Happened?

• Tap to enter information

What caused the accident (root cause)?

• Tap to enter information

Pictures. Take pictures of the scene to document.

• Click here to enter media:

  Yes

  No

  N/A

• Tap to enter information and further notes as needed.

Corrective Actions recommended:

• Tap to enter information

Corrective Actions

• Enter any corrective actions that will be undertaken

Sign Off

• On site representative

  Sign

• JCC safety committee signature

  Sign