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 by: Injured Employee Information: Nam e: Length of time with company: Facts of Accident/Illness Injur y Date reported: Illnes s / / Date of incident: / / Time of incident: Yes a.m. / p. m. No Title : In position: Title : Date: / /

Did incident occur on employer’s premise?

If not, where did it occur? If yes, where on the employer’s premise did the incident occur? Did a fatality occur? Any property Yes No If so, when? / /

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 and being worn correctly? Was the cause of the incident an unsafe condition? Was the incident caused by unsafe behavior on the part of the employee? Yes Yes

Yes No No

No

Check any applicable human, situational and environmental factors that

Accident Investigation Forms

Exhibit 9-7 (continued)

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

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 Reviewer’s Signature

Employee’s Signature Date submitted: / /