Sample

Accident Investigation Form—1

Vehicular

Name of Injured Employee ______________________

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's Account of Accident __________

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

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

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Corrective Measures to be Implemented to Prevent Similar Reoccurrence _____________________________________________________

Investigator’s Name ___________________________________

Date of Investigation __________________________________