Sample

Incident or Accident Investigation Form

Name of entity: ___________________________________

Particulars of Accident

Date of accident

Mon  Tues  Wed  Thurs  Fri  Sat  Sun  (circle appropriate day)

Time   Location    Date reported

The Injured Person

Name

Address

Age
Phone number

Date of accident

Length of employment

Length of time on this job

Type of Injury

Strain/sprain

Fracture

Laceration/cut Bruising

Scratch/abrasion

Amputation

Burn scald Dislocation

Foreign body

Internal

Chemical reaction

Other (specify)

Remarks

Injured part of body (e.g., head, back, groin, leg, arm, wrist)

Damaged Property

Property/material damaged

Nature of damage

Object/substance inflicting damage

The Accident

Description

Describe what happened (space on back for diagram—essential for all vehicle accidents)

Analysis

What were the causes of the accident?

How bad could it have been?
Very serious    Serious     Minor

What is the chance of it happening again:
Minor    Occasional    Rare

Prevention

What action has or will be taken to prevent a recurrence?

By whom

When

Check off items already in effect.

Treatment and Investigation of Accident

Type of treatment given

Name of person giving first aid

Doctor/Hospital

Accident investigated by

Date

OSHA advised YES / NO

Date