Title Page
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
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Employee Name
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Date of Accident
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Employee Job Title
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Date Reported
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Employee Department
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Investigation Date
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Accident Location
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Supervisor Name
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Supervisor Job Title
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FROI #
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Injury Type (Cur, Strain, Etc.)
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Injured Body Part
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Accident Description- Please provide a detailed description of the accident. If possible, have the employee recreate the accident; including who, what, when, where, and why.
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Contributing Factors
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Use of Safety Devices
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Use of PPE
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Equipment Condition
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Appropriate Equipment Usage
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Procedural Issues
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Speed of Operation
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Lifting Technique
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Operator Skill
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Lost Balance
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Material Handling
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Use of Tools
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Warning Method
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Type of Clothing
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Authorization Issue
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Awareness
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Housekeeping
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Condition of Surface
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Ergonomic Issue
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Guards/ Barriers
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Tools/ Equipment
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Tools/ Equipment not Available
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Lighting/ Temp/ Ventilation
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Work Area
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Exposure
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Noise
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Chemicals
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Fire/ Explosion Hazard
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Radiation
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Sharp Object
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Inclement Weather
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Training
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Root Cause Narrative- Based on your analysis, please describe what caused this accident.
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Possible Corrective Actions for Consideration (Please check all that apply)
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Isolate and Guard Hazard
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Automate a Manual Process
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Design Out/ Remove Hazard
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Add Warning Signs
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New Tools or Equipment
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Procedure Change
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Safety Training
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Ventilation
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Improve Housekeeping
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Gloves
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Respirators
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Safety Glasses
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Safety Shoes
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Hearing Protection
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Hard Hat
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Face Shield
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Cut/ Puncture Resistant Clothing
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Lab Coat
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Other
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Proposed Timely Corrective Actions
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Person(s) Responsible for Completing Timely Actions
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Investigating Safety Consultant Signature
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Date Signed
