Accident Investigation Report:

  • Accident Report Number:

  • Accident Date & Time:

Accident Type(select all that apply)

  • Near miss?

  • First Aid?

  • Medical Aid?

  • Lost Time?

  • Occupational Illness?

  • Restricted Work/Light Duty?

  • Fire/explosion?

  • Equipment failure?

  • Property Damage?

  • Material or Business Loss?

  • Motor Vehicle Accident?

  • Harassment

  • Threats/Violence

Company Information

  • Name:

  • Address:
  • Accident Address (if Different than above):
  • Phone #

  • Investigator:

  • Investigator Phone #

Employee Information:

  • Name:

  • Home Address:
  • Phone #

  • Department:

  • Job Title:

  • Employee Status:

  • Length of Employment:

  • Time in Occupation at time of accident:

Injury Information:

  • Person Reported to:

  • Date & Time Reported:

  • Type of injury

  • Body part that was injured

  • Severity of Injury:

  • Employees Specific Task and Activity at the Time of Accident:

  • Was the Employee Working:

  • Accident Report Numbers and Names of Others Injured:

  • Name of Physicians:

  • Name and Address of Hospital / Clinic:

Witnesses:

  • Name & Phone #

  • Name & Phone #

  • Name & Phone #

  • Name & Phone #

  • Name & Phone #

Scene of Accident Information:

  • Specific Location:
  • Describe How the Accident Occurred:

  • Diagram any Specific Location Factors That Contributed to the Accident:

  • Type of Equipment / Machinery Involved:

  • Equipment / Machinery Has been:

Accident Sequence: Describe in order of occurrence the events leading to the accident and/or injury. Reconstruct the sequence of events that led to the accident.

  • Event# 1

  • Event# 2

  • Accident Event:

  • Injury Event:

Analysis-Describe events and conditions that contributed to the accident. Include information on worker, machinery and equipment, environment and management.

  • Immediate causes, which acts or failure to act and conditions contributed directly to this accident?

  • Basic causes, what are the contributing factors?(job factors, personal factors)

Incident Severity

  • Incident Severity

Frequency Potential

  • Frequency Potential

Corrective Actions: Identify the factors listed above that can be corrected to prevent a reoccurrence of this type of accident. Indicate the person responsible for making the change and project a target date for completion of the task. Use the diagram grid below to illustrate layout changes.

  • Corrective action:

  • Corrective action:

  • Assignment Responsibilities:

  • Target Date for Completion:

  • Diagram Annotations:

  • Diagram media(photos etc):

Additional Information

  • Pictures:

  • Summary: Include comments that would promote a safe workplace environment and reduce an accidents potential in the future based on review of the causal Factors and implementation of Corrective Actions.

Costs- Costs include fines, penalties, property Damage, medical costs, workers compensation payments, legal fees, overtime costs caused by accident, supervisor/safety overtime for investigation, travel expenses, repairs etc. Both direct and indirect costs.

  • Estimated

  • Actual

This Accident Investigation Report was prepared by:

  • Signature:

  • Date:

  • Title:

  • Department:

Approved by ( If Corrective action is required.)

  • Title:

  • Signature:

  • Date:

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