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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