JR Accident/Incident Investigation Report

• Document No.

• Audit Title

• Client / Site

• Date reported

  Date

• Prepared by

• Location
  Address

Accident Investigation Report:

• Accident Report Number:

• Accident Date & Time:

  Date

Accident Type(select all that apply)

• Near miss?

  Yes

  No

  N/A

• First Aid?

  Yes

  No

  N/A

• Medical Aid?

  Yes

  No

  N/A

• Lost Time?

  Yes

  No

  N/A

• Occupational Illness?

  Yes

  No

  N/A

• Restricted Work/Light Duty?

  Yes

  No

  N/A

• Fire/explosion?

  Yes

  No

  N/A

• Equipment failure?

  Yes

  No

  N/A

• Property Damage?

  Yes

  No

  N/A

• Material or Business Loss?

  Yes

  No

  N/A

• Motor Vehicle Accident?

  Yes

  No

  N/A

• Harassment

  Yes

  No

  N/A

• Threats/Violence

  Yes

  No

  N/A

Company Information

• Name:

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

• Phone #

• Investigator:

• Investigator Phone #

Employee Information:

• Name:

• Home Address:
  Address

• Phone #

• Department:

• Job Title:

• Employee Status:

  Select Full Time Part Time Temporary Other

  • Full Time
  • Part Time
  • Temporary
  • Other

• Length of Employment:

  Select Less Than 1 Month 1 - 5 Months 6 Months to 5 Years More Than 5 Years

  • Less Than 1 Month
  • 1 - 5 Months
  • 6 Months to 5 Years
  • More Than 5 Years

• Time in Occupation at time of accident:

  Select Less Than 1 Month 1 - 5 Months 6 Months to 5 Years More Than 5 Years

  • Less Than 1 Month
  • 1 - 5 Months
  • 6 Months to 5 Years
  • More Than 5 Years

Injury Information:

• Person Reported to:

• Date & Time Reported:

  Date

• Type of injury

• Body part that was injured

• Severity of Injury:

  Select Fatality Lost Days-Days Away from work Days of Restricted Activity or job Transfer Medical Treatment First Aid

  • Fatality
  • Lost Days-Days Away from work
  • Days of Restricted Activity or job Transfer
  • Medical Treatment
  • First Aid

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

• Was the Employee Working:

  Select Working Alone Working with assigned group Supervised Not Supervised

  • Working Alone
  • Working with assigned group
  • Supervised
  • Not Supervised

• 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:
  Address

• Describe How the Accident Occurred:

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

  Drawing

• Type of Equipment / Machinery Involved:

• Equipment / Machinery Has been:

  Select Out of Service Repaired

  • Out of Service
  • Repaired

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

  1-Catastrophic

  2-Critical

  3-Serious

  4-Minor

  5-Negligible

Frequency Potential

• Frequency Potential

  A) Very Likely

  B) Likely

  C) Possible/maybe

  D) Low

  E) Very Low

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:

  Drawing

• Diagram media(photos etc):

  Media

Additional Information

• Pictures:

  Media

• 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:

  Sign

• Date:

  Date

• Title:

• Department:

Approved by ( If Corrective action is required.)

• Title:

• Signature:

  Sign

• Date:

  Date