Sample workplace accident investigation form
Accident information
Date of accident: __________________________________ Date of report: _______________________________________
Where did the accident occur? ___________________________________________________________________________
Time of accident: __________________
- a.m.
- p.m.
- On site
- Off site
Name(s) of injured: ____________________________________________________________________________________
Are these company employee(s)?
- Yes
- No
Contractors?
- Yes
- No
Names of non-company individuals (if applicable): ____________________________________________________________
____________________________________________________________________________________________________
Occupation of employee(s): ______________________________________________________________________________
Witnesses to accident: __________________________________________________________________________________
Description of any property damage: _______________________________________________________________________
____________________________________________________________________________________________________
Description of events: __________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Contributing factors
Act(s) (describe): ______________________________________________________________________________________
____________________________________________________________________________________________________
Conditions (describe): __________________________________________________________________________________
____________________________________________________________________________________________________
Root cause(s) of accident: _______________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Corrective actions to take
(Describe what actions need to be taken to prevent a reoccurrence)
|
Corrective action |
Person responsible |
Date completed |
|---|---|---|
Report developed by:______________________________________ Dept.: ______________________________________
Report reviewed by:_______________________________________ Date:_______________________________________
To learn more about Hanover Risk Solutions,
This material is provided for informational purposes only and does not provide any coverage or guarantee loss prevention. The examples in this material are provided as hypothetical and for illustration purposes only. 华体会 Insurance Company and its affiliates and subsidiaries (鈥溁寤徕�) specifically disclaim any warranty or representation that acceptance of any recommendations contained herein will make any premises, or operation safe or in compliance with any law or regulation. By providing this information to you, 华体会 does not assume (and specifically disclaims) any duty, undertaking or responsibility to you. The decision to accept or implement any recommendation(s) or advice contained in this material must be made by you.
171-0830 (1/14) LC 12鈥�169