11/22/2020 Accident_Investigation

TOOLBOXTOPICS.COM
Project Name: Project Location:

Investigated By: Date: Supervisor

Equipment involved

ACCIDENT/INCIDENT INVESTIGATION

REPORT

Personal Injury____________________________ Property Damage__________________________

Name:_________________________________Employee#: _________________________________
Hire Date:_______________________Performing Regular Job:__________________________________________
Type of Injury:__________________________________Nature of Injury:___________________________________
Part of Body Injured:________________________________Nature of Damage:______________________________

Description of Accident: (What occurred? Include photos and diagram.)

Cause of Accident: (How and why did it occur. Documentation to support training.)

Witnesses: (Anyone who may have seen the accident occurred. Name, company, phone#)

Corrective Actions: (Actions taken to prevent recurrence.)

This document contains privileged, limited-use safety and privacy act protected information. Unauthorized use or disclosure can subject
you to criminal prosecution, termination of employment, civil liability, or other adverse actions.

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