Sunday 14 October 2012

ACCIDENT/INCIDENT INVESTIGATION REPORT

ACCIDENT/INCIDENT INVESTIGATION
REPORT
FOR OFFICIAL USE ONLY
This document contains privileged, limited-use safety and privacy act protected information.  Unauthorized use or disclosure can subject you to criminal prosecution, termination of employment, civil liability, or other adverse actions.
Project Name: Project Location:
Completed By: Date: Accident Date: Time:
Personal Injury
Property Damage
Name: Property Damaged:
Employee#: Hire Date: Nature of Damage:
Performing Regular Job:
Type of Injury:
Nature of Injury:
Part of Body Injured:

Description of Accident:  (What occurred?  Include photos and diagram.)

Cause of Accident:  (How and why did it occur. Documentation to support training.)

Witnesses:  (Anyone who may have seen the accident occurred. Name, company, phone#)

Corrective Actions:  (Actions taken to prevent recurrence.)

No comments:

Post a Comment