Accident Investigation Forms

OSHA Case #:

Accident Investigation Report

Each incident, whether serious or minor, should be investigated to prevent
recurrence. The real causes can be determined and corrected only after thorough
investigation which may include interviews with the injured and witnesses and a
visit to the scene of the incident. The purpose of this form is not to pass blame,
but simply to avoid repetition of a similar incident. This form must be completed
within six (6) days of the incident and retained on file for five (5) years in order to
comply with OSHA regulations governing workplace incidents. (To be completed by
the immediate supervisor in coordination with the Human Resources Director and
the Operations Manager.)

Employer Information:

Prepared Title Date: / /

by: :

Injured Employee Information:

Nam Title
e: :

Length of time with In

company: position:

Facts of Accident/Illness

Injur Illnes Date of incident: / / Time of a.m. / p.

y s incident: m.

Date / / Did incident occur on employer’s Yes No

reported: premise?

If not, where did it

occur?

If yes, where on the employer’s premise did

the incident occur?

Did a fatality Yes No If so, when? / /

occur?

Any property
Accident Investigation Forms Exhibit 9-7 (continued)

damage?

What was the employee doing when the incident occurred? (Please be specific. If
the employee was using tools or equipment or handling material, name them and
explain what the employee was doing with them.)

Explain how the incident occurred. List events that resulted in the injury, what
happened, how it happened, and name tools and objects and how they were
involved.

Describe the specific cause of

the injury:

Describe the injury (i.e. part of the

body affected, etc.):

Describe the conditions of the area in which

the injury occurred:

Was the appropriate personal protective equipment provided Yes No

and being worn correctly?

Was the cause of the incident an unsafe condition? Yes No

Was the incident caused by unsafe behavior on the part Yes No

of the employee?

Check any applicable human, situational and environmental factors that

Accident Investigation Forms Exhibit 9-7 (continued)

contributed to the incident

Improper instruction Failure to look out Improper guarding

Lack of training or skill Unsafe position Improper
maintenance
Operating without Unsafe equipment Inoperative safety
authority device
Horseplay Poor housekeeping Improper
equipment use
Physical or mental Unsafe Other
impairment arrangement/process
Failure to secure Poor ventilation

What actions do those involved recommend to prevent similar incidents from

occurring in the future?

Review
comments:

What actions are the employee taking to

prevent recurrence:

Review
comments:

Supervisor’s Signature Employee’s Signature

Reviewer’s Signature Date / /

submitted: