Title Page
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Injured Employee Name
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Foreman Name
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Job Number
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Accident Date and time
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Report Prepared by
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Accident Location
Accident Information
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Date and time accident reported to foreman
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Describe how the event happened
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What unsafe acts and/or unsafe conditions led to the incident occurring?
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Was the employee injured? If so, describe his/her injuries and how those injuries occurred
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Describe the employee's behavior after the accident
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What type of medical treatment did the employee receive?
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Was the employee sent for a drug screen?
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Describe what the employee was doing at the time of the accident
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How experienced was this employee with performing this task?
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What tools and equipment were being used at the time of the accident?
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Were there any environmental factors that contributed to the accident?
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What could have been done to prevent this accident from occurring?
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What instructions had the foreman given to the employee?
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Was the Foreman observing the employee at the time of the injury/accident?
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Had the employee been trained by the Foreman for this particular task?
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Does the employee need additional training for this task?
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Was this work process discussed in the morning JHA (Job Hazard Analysis)? Describe.
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Describe any time concerns for this task?
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Was a tool or equipment defective? If so, describe.
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Is there a better tool or process that could have been used?
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What corrective actions have been taken to prevent recurrence?
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Where were the witnesses and what were they doing at the time of the accident?
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Provide names and contact information for the witnesses
Employee Information
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Was this a Key Constructors employee?
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How long has this employee been employed by Key Constructors?
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What is the employee's job position?
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What is the employee's daily work shift hours?
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How many hours had the employee worked the day of the accident?
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How many hours had the employee worked the week of the accident?
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When was the employee's last day off work?
