ACCIDENT / INCIDENT INVESTIGATION REPORT
Project Name: _____________________________________________
Location: _________________________________________________
Date: ________________________ Time: _______________________
A. General Information:
Victim’s Name: _______________________________________________________________________
Age: _____________________ Designation: _______________________________________________
Accident/incident’s Location: ______________________________ Date & Time: ___________________
Experience of his/her job (which he/she was doing): __________________yrs. ______________ months
Contractor’s Name: ____________________________________________________________________
Name of immediate supervisor: __________________________________________________________
Property Damaged/stage nature: _________________________________________________________
Name and Occupation of witness: ________________________________________________________
Type(s) of Accident (Tick):
*Fatality ( ), *Lost Time ( ), * First Aid ( ), *Property Damage ( ),
*Dangerous – Occurrence ( ), * Near Miss ( ), *Others ( )
B. Injury Information:
Type & Nature of injury: ________________________________________________________________
Parts of body affected: _________________________________________________________________
Agency of Accident (Energy Source): ______________________________________________________
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C. Treatment:
First Aid:
____________________________________________________________________________________
____________________________________________________________________________________
Outside treatment (if any):
Name of Clinic/Hospital: _______________________________________________________________
Treatment Given: ____________________________________________________________________
____________________________________________________________________________________
Number of working day lost: _____________________________________________________________
D. Description of Accident:
Description of damage & losses (What, Why, How, When, Where, Whom)
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
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E. Root Cause Analysis:
➢ First Report (Data to be collected from victim/witness):
_____________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
➢ Immediate Cause:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
➢ Intermediate Cause:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
➢ Basic Cause:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
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F. Prevention Action:
➢ What immediate action has been taken?
_______________________________________________________________________
_______________________________________________________________________
➢ What interim action has/will be taken to prevent recurrence?
_______________________________________________________________________
_______________________________________________________________________
➢ What final corrective action has/will be taken to prevent recurrence?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
G. Reviewer Comments on analysis:
_____________________________________________________________________________
_____________________________________________________________________________
____________________________________________________________________________
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NAME OF PROJECT EHS OFFICER/HEAD SIGNATURE DATE
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NAME OF PROJECT MANAGER / SITE IN-CHARGE SIGNATURE DATE
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