Accident Investigation Form—2
To be sent to ________________________________
[Insert title or person, e.g., Safety Director, Safety Manager, Safety Officer, Chair Safety Committee, Chief Elected Official’s title] 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): _______________________
- 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:
- Was/were the person(s) involved appropriately trained and authorized?
Give brief details of relevant training and authorization:
- Are there any written rules or other instructions applicable to the work?
If so give brief details:
- Was there any apparent breach of rules or instructions, or any apparent malpractice? If so, give details:
- Supervisor’s additional comments:
Supervisor’s signature Date
APPROPRIATE MANAGER TO COMPLETE PARTS 6-10
- Do you endorse the supervisor’s replies to Parts 1 to 5? If not, what would you alter, delete or add?
- Is there any need to modify or add to existing rules or instructions?
If so, what modification or addition needs to be made?
- Has the investigation identified any training need? If so, give details:
- What action have you taken in respect of this accident?
- 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, Chief Elected Official’s title]