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.) |
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