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Accident Investigation Report

The document is an Accident Investigation Report that collects essential information regarding an employee injury, including details about the injured person, the nature of the accident, and the causes. It also addresses the use of personal protective equipment, witness accounts, safety training, and corrective actions taken. The report concludes with signatures from the supervisor and safety coordinator, along with follow-up actions.

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mazen fakhfakh
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28 views1 page

Accident Investigation Report

The document is an Accident Investigation Report that collects essential information regarding an employee injury, including details about the injured person, the nature of the accident, and the causes. It also addresses the use of personal protective equipment, witness accounts, safety training, and corrective actions taken. The report concludes with signatures from the supervisor and safety coordinator, along with follow-up actions.

Uploaded by

mazen fakhfakh
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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ACCIDENT INVESTIGATION REPORT

REPORT #

COMPANY:
ADDRESS:

1. Name of injured: S.S. #:


2. Sex: M F Age: Date of accident:
3. Time of accident: am pm Day of accident:
4. Employee’s job title:
5. Length of experience on job: (years) (months)
6. Address of location where the accident occurred:

7. Nature of injury, Injury type, and Part of the body affected:

8. Describe the accident and how it occurred:

9. Cause of the accident:

10. Was personal protective equipment required? Yes No


Was it provided? Yes No
Was it being used as trained by supervisor or designated trainer?
Yes No If “no”, explain

11. Witness(es):

12. Safety training provided to the injured? Yes No If “no”, explain

13. Interim corrective actions taken to prevent recurrence:

14. Permanent corrective action recommended to prevent recurrence:

15. Date of report


Prepared by:

Supervisor (Signature) Date:

16. Status and follow-up action taken by safety coordinator:

Safety Supervisor (Signature) Date:

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