PISD Safety Investigation

• Employee Name

• Document No.

• Site

• Conducted on

  Date

• Prepared by

Site details

• Site employee was working at?

• Principal's Name? (If campus based)

• Name of Immediate Supervisor?

Accident/Incident Details

• Date and time of injury;

  Date

• Employee Name

• Job Tittle

• Location of accident (please be specific)

• Brief statement of what incident was? (Just the Facts)

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

Preventative Actions

• What immediate preventive actions are being taken for this incident?

• What long term preventive measure is being implemented to minimize possible recurrence?

• Who is the responsible person for ensuring these preventive actions are implemented?

• Has the person responsible above been informed and understand the expected preventative plan?

  Yes

  No

  N/A

• Signature of person responsible for preventative plan.

  Sign

• Follow up date for ensuring preventive measures are being maintained.

  Date

Injured Party statement

• If the injured party has any additional comment or statement, please summarize.

• Name & Signature of the injured party

  Sign

Witness statements

• Witnesses 1

• Name and signature of the witness 1

  Sign

• Witnesses 2

• Name and signature of the witness 2

  Sign

Additional Information

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

  Media

Investigation Conclusions

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Person Completing Form (please sign below)

• Is the above report a true reflection of the Accident / Incident

  Sign