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.

  • Specialist 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

Person Completing Form (please sign below)

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

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