Accident Investigation Form \ Sample-1

Vehicular

Name of Injured Employee/Volunteer ______________________

Date of Accident ______________________________________

Job Title _____________________________________________

Time of Accident ______________________________________

Department __________________________________________

Location of Accident ___________________________________

Name of Witness(s) ____________________________________


Description of Accident _________________________________

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Task Being Performed __________________________________

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Equipment, Tools, Personal Protective Equipment, Procedures Being Used

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Description of Injury/Illness (include accident type, injury type and body part injured)
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Describe All Contributing Factors _________________________

Description of Work Area _______________________________


Injured Employee/Volunteer's Account of Accident __________

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Witness's Account of Accident: (Name, title, address, phone number)

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What Were the Basic Causes of the Accident (usually multiple causes)?

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Corrective Measures to be Implemented to Prevent Similar Reoccurrence

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Investigator's Name ___________________________________

Date of Investigation __________________________________