Accident Investigation Form \ Sample-2

To be sent to [Insert title or person, e.g., Safety Director, Safety Manager, Safety Officer, Chair Safety Committee, Executive Director] within 14 days of the date of the accident

This side to be completed by the appropriate supervisor

Date of Accident/Occurrence: _____________ Time: ________

Place of Accident/Occurrence: __________________________

Name of injured person(s) (if any): _______________________

____________________________________________________

  1. Was/were any other person(s) involved in, or witness to, the accident? If so give employee(s) name(s), titles, departments, phone numbers; if not an employee, record name, company, phone number:

     

     

  2. Was/were the person(s) involved appropriately trained and authorized?
    Give brief details of relevant training and authorization:

     

     

  3. Are there any written rules or other instructions applicable to the work?
    If so give brief details:

     

     

  4. Was there any apparent breach of rules or instructions, or any apparent malpractice? If so, give details:

     

     

  5. Supervisor's additional comments:

     

     

  6. ________________________________________________
    Supervisor's signature                            Date

     

     


    Page 2

    APPROPRIATE MANAGER TO COMPLETE PARTS 6-10

     

  7. Do you endorse the supervisor's replies to Parts 1 to 5? If not, what would you alter, delete or add?

     

     

  8. Is there any need to modify or add to existing rules or instructions?
    If so, what modification or addition needs to be made?

     

     

  9. Has the investigation identified any training need? If so, give details:

     

     

  10. What action have you taken in respect of this accident?

     

     

  11. Do you see any need for preventative action outside your department? If so, give details of the action and other departments concerned:

     

     

    ________________________________________________
    Manager's signature                            Date

When complete, this form should be sent immediately to [Insert title or person, e.g., Safety Director, Safety Manager, Safety Officer, Chair Safety Committee, Executive Director]