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Accident Investigation Form

This document is an accident investigation form that contains sections to be filled out by a supervisor and manager after an accident, incident, or dangerous occurrence. The form requests details about the event such as date, location, people involved, witnesses, training and rules, apparent causes, and corrective and preventative actions. It aims to gather all relevant information about the event to be sent to heads of Environmental Health and Safety and Human Resources within 24 hours.

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Prem Shanker Rawat
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© Attribution Non-Commercial (BY-NC)
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308 views2 pages

Accident Investigation Form

This document is an accident investigation form that contains sections to be filled out by a supervisor and manager after an accident, incident, or dangerous occurrence. The form requests details about the event such as date, location, people involved, witnesses, training and rules, apparent causes, and corrective and preventative actions. It aims to gather all relevant information about the event to be sent to heads of Environmental Health and Safety and Human Resources within 24 hours.

Uploaded by

Prem Shanker Rawat
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Accident Investigation Form

To be sent to Head EHS/ Head HR within 24 hours of the date of the Accident/Incident /Dangerous Occurrence This side to be completed by the appropriate supervisor Date of Accident/Incident /Dangerous Occurrence: _____________ Time: ________ Place of Accident/Incident /Dangerous Occurrence: __________________________ Name of injured person(s) (if any): _______________________ E. Code No. ________________ _________________________ E. Code No. ________________ _________________________ E. Code No. ________________ _______________________ E. Code No. ________________

1. Was/were any other person(s) involved in, or witness to, the Accident/Incident /Dangerous Occurrence? If so
give employee(s) name(s), titles, departments, phone numbers. If not an employee, record name, company, phone number:

2.

Was/were the person(s) involved appropriately trained and authorized? Give brief details of relevant training and authorization:

3.

Are there any written rules or other instructions applicable to the work? If so give brief details:

4. Was there any apparent breach/ violation of rules or instructions, or any apparent malpractice? If so, give
details:

5.

Supervisor's additional comments:

________________________________________________ Supervisor's signature Date

APPROPRIATE MANAGER TO COMPLETE PARTS 6-11

6.

Do you endorse the supervisor's replies to Parts 1 to 5? If not, what would you alter, delete or add?

7. Is there any need to modify or add to existing rules, procedures or instructions?


If so, what modification or addition needs to be made?

8.

Has the investigation identified any training need? If so, give details:

9. What corrective action have you taken in respect of this accident?

10. What preventive action have you taken in respect of this accident?

11. 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 Head EHS & Head HR

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