• Injured Employee Name:

  • Date of injury

This section to be filled out by employee

  • Adreess of employee

  • Employees phone number

  • employees date of birth

  • Date and time of injury

  • Time your shift started on day of injury

  • Department

  • Ware did the accident happen- be specific

  • Give a description of the incident

  • Type of injury/illness

  • explain

  • What part of body is hurt- add photo of injury if appropriate

  • Job title

  • How long have you been on this Job? not with the company but this job

  • Supervisor(s) on duty

  • Do you work for another employer?

  • Who?

  • Employee signature

Witness Statement 1

  • What did you see happen

  • Add signature

Witness Statement 2

  • What did you see happen?

  • Add signature

To be filled out by supervisor

  • Was a safety stand down conducted?<br>

  • Was the Triage Nurse called

  • Why not?

  • Was injury reported the day it happened?

  • If no Why

  • Did employee receive medical attention?

  • what kind of care?

  • who?

  • Was injured admitted for overnight hospital stay?

  • Task being preformed at time of injury

  • Materials/equipment used

  • What was employee doing right before injury

Machinery/Equipment involved - to be filled out by Supervisor

  • Was equipment or machinery involved? <br>

  • What Equipment

  • Was there any mechanical failure?

  • Explain

Contributing Factors - To be filled out by supervisor

  • Contributing Factors: Description why this factor contributed or caused the incident (Typically there is more than a single casual factor):

  • Contributing Factors Photo

  • Contributing Factors Photo

  • Was there an Unsafe Condition?

  • What unsafe Condition

  • Was there an Unsafe Act


  • Did employee receive specific training or instructions relating to safety and health on job being performed?<br>

  • Type

  • Instructed by

  • Date of last refresher training

Personal Protective Equipment

  • Did employee use appropriate PPE for the job/task performed?

  • Did equipment fail? If so, describe

  • Describe failure of equipment

Root Cause Analysis

  • How did the injury occur?

  • Why did that occur? (answer from last question)

  • Why did that occur? (answer from last question)

  • Why did that occur? (answer from last question)

  • Why did that occur? (answer from last question)

  • Why did that occur? (answer from last question)

  • What is the Root Cause?

Corrective Actions - To be filled out by EHS

  • Were any corrective or preventative actions taken due to the incident?

  • What actions

  • Is retraining required?<br>

Management/Administrative actions

  • Is any further action required? If yes, state action to be taken

  • What action ?

  • Are all corrective actions completed?

  • What corrective action is not completed?

  • when will it be completed?

  • Is unsafe condition eliminated or mitigated to prevent future unsafe acts or conditions from occurring?

  • Why Not

  • Is Plant management satisfied with plan of action and investigation


  • Supervisor

  • Department Head

  • Plant Mgr.

  • Safety Mgr.

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.