ACCIDENT INVESTIGATION REPORT

Date of Accident: Date of Investigation: Location of Accident: Did Injury Result? Yes/No Social Sec. No.: Describe Type of Injury: Was Property Damaged? Yes/No: Describe damage/owner: If yes, provide Employee Name(s): Yrs. In this Skill: Time of Accident: Job Number: Company: Client:

Skill:

Yrs. With Company:

Is damaged property secured/maintained? Yes/No: Names of Witnesses/Co-workers (With Social Security No.)

Person Maintaining:

Weather/Wind Conditions: List/Describe all personal protective equipment (PPE) in use by person exposed or injured:

If Chemicals Involved: Name(s) of Chemical(s) Encountered:

Form of Chemicals (Solid, Liquid, Gas, Vapor, Dust, Mist Fume): Describe Radiological Materials (if any): Volume or Quantity Released: Description of Accident:

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Contributing Factors:

What corrective actions are being taken to prevent recurrence? Also list the person responsible for implementing and the target completion date for each item.

If yes, attach a copy. Was an SPA/JSA developed for the task being performed? Yes/No: Was a permit issued? Yes/ No? Indirect cause of accident: Lack of: Basic cause of Plan accident: Failure to: Training Direct Resources Organize If yes, attach a copy of the permit in effect at time of the accident. Belief Control (*explain) (*explain)

INVESTIGATION TEAM MEMBERS: Injured/Involved: Name Supervisor: Name Site Manager: Name Health & Safety Rep.: Name Signature Signature Signature Signature

Name (Others)

Title

Signature

Name (Others) Client Representative(s) Contacted: Agency Representative(s) Contacted:

Title

Signature

* Attach additional sheets and supplemental data & information as necessary. ** Distribution: Original must be filed on-site; 1 copy must be sent to the Corporate Health and Safety Department.

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