Part A. Accident/Incident portion.

  • Select date

  • Name Branch that employee was working for:

  • Employee Name (First, MI, Last): (Look at ID)

  • SSN #

  • Date of Birth:

  • Did employee die?

  • Gender:

  • Date of Injury/Icident:

  • Time of Injury/Incident:

  • Return to work date/or expected date:

  • Will the employee have any restrictions?

  • If so, what are they?

  • Do we have Light Duty for him based on restrictions?

  • Date and Time the employer was notified:

  • Employee's Home Address and Phone Number:

  • Does Employee Speak English?

  • What Language?

  • Marital Status:

  • Number of Dependents:

  • Number of Dependents under 18:

  • Spouse's Name:

  • Hire Date:

  • Avg. Hrs Worked Per Week:

  • Avg. Weekly Wage:

  • Job Title:

  • Did He Receive Full Pay For Date Of Injury?

  • Superintendent Name and Phone Number:

  • Project Name, Number and Address Where Accident Occurred:

  • Witnesses?

  • Witnesses?

  • If the answer was yes, please provide Full Name, Phone Number and Employer:

  • If the answer was yes, please provide Full Name, Phone Number and Employer:

  • Where was the Medical Treatment first provided?

  • What type of provider performed treatment?

  • Providers Name:

  • If you choose other please specify.

  • Provider Phone Number, Address and Name of the Doctor.

  • Anyone else injured:

  • Name of the Superintendent and/or other office personnel who went with the injured to the clinic/hospital. This is mandatory and must stay there the entire time.

  • Nature of Injury?

  • Part of Body injured:

  • Was the employee doing his regular job?

  • Describe who, what, when,where, why and how injury occurred:

  • Location of accident (please be specific)?

Person Completing Part A ( please sing below)

  • Add signature

Part B. Investigation portion.

  • Employee Name (First, MI, Last):

  • Contract Relationship (Company Name):

  • Date of Hire:

  • Was the person injured a new hire?

  • Which one applies to the accident / incident:

  • Total Yrs. of experience:

  • Incident Type:

  • Please explain further:

  • Severity:

  • Was a Pre-Job Safety Briefing Held before work began?

  • Was employee present?

  • Describe the work Activity in Progress at the time of the incident. (What was the Employee doing? How did the Incident occur?)

  • Describe the Incident. (Where was the employee? What was the employee doing? How did the Incident occur?)

  • Cause or Causes of the incident: (Inadequate PPE, Not Paying attention to surroundings, failure to utilize safety equipment)

  • Contributing causes of the Incident: (Inadequate training, Inadequate supervision. Employee not following proper safety procedures and instructions)

  • What is the employee's current status if injured: Describe. ( Returned to work the next day, off of work do to injury, off of work do to restrictions, In hospital, etc.)

Corrective Actions

Action:

  • What was the immediate action taken to correct the issue (how was this done)?

  • Who was the responsible party for correcting the issue?

  • Select date

Action:

  • What is the long term action needed to correct the issue?

  • Who was the responsible party for correcting the issue?

  • Select date

  • Lessons Learned:

  • Please provide all attachments that apply: Pictures, Drawings, Training Records, Statement of Employee, Statement of Witness/es, Other.

Statement of Employee involved in the accident/incident

  • Please provide date of incident,time, phone number and description of the incident according to the employee in his words:

  • Add signature

Statement of the Witness (1)

  • Name of witness, Company that he / she works for, Phone Number, Date and Time of the accident/incident according to the witness.

  • Statement in his words:

  • Add signature

Statement of the Witness (2)

  • Name of witness, Company that he / she works for, Phone Number, Date and Time of the accident/incident according to the witness.

  • Statement in his words:

  • Add signature

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. Any ratings or scores displayed in our Public Library have not been verified by SafetyCulture for accuracy. Users of our platform may provide a rating or score that is incorrect or misleading. You should independently determine whether the template is suitable for your circumstances. You can use our Public Library to search based on criteria such as industry and subject matter. Search results are based on their relevance to your search and other criteria. We may feature checklists based on subject matters we think may be of interest to our customers.