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Accident Investigation Report

An accident investigation report provides details of a workplace accident that occurred on a specific date at a given location. It describes whether any injuries or property damage resulted from the accident. The report identifies the employee(s) involved, their experience level, and the job details. It also lists any witnesses, weather conditions, protective equipment used, and chemicals involved. The report analyzes contributing factors and corrective actions needed to prevent future accidents. An investigation team signed off on the report which was distributed according to protocol.

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Michael Miotk
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© Attribution Non-Commercial (BY-NC)
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113 views

Accident Investigation Report

An accident investigation report provides details of a workplace accident that occurred on a specific date at a given location. It describes whether any injuries or property damage resulted from the accident. The report identifies the employee(s) involved, their experience level, and the job details. It also lists any witnesses, weather conditions, protective equipment used, and chemicals involved. The report analyzes contributing factors and corrective actions needed to prevent future accidents. An investigation team signed off on the report which was distributed according to protocol.

Uploaded by

Michael Miotk
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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ACCIDENT INVESTIGATION REPORT

Date of Accident: Date of Investigation: Location of Accident: Did Injury Result? Yes/No Social Sec. No.: Describe Type of Injury: Was Property Damaged? Yes/No: Describe damage/owner: If yes, provide Employee Name(s): Yrs. In this Skill: Time of Accident: Job Number: Company: Client:

Skill:

Yrs. With Company:

Is damaged property secured/maintained? Yes/No: Names of Witnesses/Co-workers (With Social Security No.)

Person Maintaining:

Weather/Wind Conditions: List/Describe all personal protective equipment (PPE) in use by person exposed or injured:

If Chemicals Involved: Name(s) of Chemical(s) Encountered:

Form of Chemicals (Solid, Liquid, Gas, Vapor, Dust, Mist Fume): Describe Radiological Materials (if any): Volume or Quantity Released: Description of Accident:

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Contributing Factors:

What corrective actions are being taken to prevent recurrence? Also list the person responsible for implementing and the target completion date for each item.

If yes, attach a copy. Was an SPA/JSA developed for the task being performed? Yes/No: Was a permit issued? Yes/ No? Indirect cause of accident: Lack of: Basic cause of Plan accident: Failure to: Training Direct Resources Organize If yes, attach a copy of the permit in effect at time of the accident. Belief Control (*explain) (*explain)

INVESTIGATION TEAM MEMBERS: Injured/Involved: Name Supervisor: Name Site Manager: Name Health & Safety Rep.: Name Signature Signature Signature Signature

Name (Others)

Title

Signature

Name (Others) Client Representative(s) Contacted: Agency Representative(s) Contacted:

Title

Signature

* Attach additional sheets and supplemental data & information as necessary. ** Distribution: Original must be filed on-site; 1 copy must be sent to the Corporate Health and Safety Department.

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