MECO- Accident Investigation

• Document No.

• Audit Title

• Conducted on

  Date

• Conducted by

• Location
  Address

• Personnel

Injured Employee Data

• Employee Name

• Employee Classification / Job Title

• Employee Home Address (or where currently residing)
  Address

• Home Telephone Number

• Mobile Telephone Number

• Job Number and Name of Project Where Injury Occurred

• Address of Project
  Address

• Date and Time of Accident

  Date

• Supervisor Name

• Supervisor Telephone Number

Accident Description

• Where did the accident happen and who was involved? Provide a full description of the surroundings of the location and the individuals involved.

• Photos of Scene

  Media

• Drawing/Layout of Accident Area

  Drawing

• What was happening at the time of the accident and why was it taking place?

• What were the events leading up to the accident? Describe the sequence in order and when they took place.

• Was there any equipment involved?

  Yes

  No

• Name all equipment involved

• Were there any tools involved?

  Yes

  No

  N/A

• Name all tools involved

• What exactly caused the injury and how did it happen?

• Describe the injury or injuries incurred. What body part and what type of injury?

Accident Findings

• After review of all facts, what was the hazardous condition, unsafe work practice, or other causal factors (procedure, equipment, people and environment) that contributed to the accident/injury?

Corrective Action

• What is recommended to prevent this type of accident from occurring again?

• Actions taken to ensure recommendations are considered:

• Date by which all corrective measures will be implemented:

  Date

• Signature of supervisor responsible for corrections

  Sign