Information

  • Employee Name

  • Document No.

  • Site

  • Conducted on

  • 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;

  • 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?

  • Signature of person responsible for preventative plan.

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

Injured Party statement

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

  • Name & Signature of the injured party

Witness statements

  • Witnesses 1

  • Name and signature of the witness 1

  • Witnesses 2

  • Name and signature of the witness 2

Additional Information

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

Investigation Conclusions

  • undefined

Person Completing Form (please sign below)

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

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.