M M / D D / YR

Date of Report ACCIDENT INVESTIGATION REPORT Report No.

DRAFT
"IT TAKES LONGER TO REPORT AN ACCIDENT THAN TO PREVENT ONE"
The unsafe acts and conditions that cause accidents can be corrected only when they are known. It is everyone’s responsibility to report accidents, correct them , or
state their remedy. (Shift Supervisor fill out all items with red headings.)

Facility: Site location address: Location No:

Workers’ Comp Administrator: Client/Program ID:

Please Print
For this Employee ID section only, HR will complete shaded blocks
Employee Name (last) First Name M.I. Sex Date of Birth Length of Service
Employee ID

Job Title Department Wages: / Home Phone #

(
Time Employee Started Shift: Supervisor Home Address
AM / PM
Paid wages for day of injury? Date of Hire Length of Service City State Zip
Yes No

Date of Incident Day of Week Time of Injury Date Reported to Company Date Employee Claim Form Provided
M M / D D / YR AM / PM
OSHA Notification Person Contacted Severity:
Yes No Fatality Days Away(LT) DART Recordable 1st
See also page 2 Aid

Injury/Illness Type: (Check One)

Strain/Sprain Laceration (cut/puncture) Struck By Struck Against Eye Injury Fall / Slip (Same Level)
Fall / Slip (Lower Level) Caught In/On/Between Burns
Industrial Hygiene Hearing Other Illness

Brief Description.

What was the employee doing just before the incident occurred? Describe the activity, as well as the tools, equipment or material the employee
INJURY/ILLNESS INCIDENT

was using. Be specific. Examples: “climbing a ladder while carrying materials”; “ spraying chlorine with hand sprayer”; “daily computer key entry”

What happened? Tell us how the injury occurred. Examples: “When ladder slipped on wet floor, worker fell 20 feet”; Worker was sprayed with
chlorine when gasket broke during replacement”; Worker developed soreness in wrist over time”.

What was the injury or illness? Tell us the part of the body that was affected and how it was affected; be more specific than “hurt”, “pain”, or “sore”.
Examples: “strained back”; “chemical burn - hand”; “carpal tunnel syndrome”.

What object or substance directly harmed the employee? Examples: “concrete floor”; “chlorine”; “radial arm saw”. If this question does not apply,
leave it blank.

Sequence of events following the accident: (immediately after event)? E.g. Danger tape put up, signs posted, chemical company called, etc)

Investigation: (Check all that apply)

Investigation made at the scene No Investigation made at the scene Photos taken of the scene
Discussed with others Not Discussed with others Employee counseled (if accident due to negligence / unsafe act)
Witnesses: No Yes – List info on back or additional page (attach statement) Others injured in same event: No Yes – List info on back or additional page

Date returned to work Time Returned

Time Began Work on Date of injury Unable to work 1 full day after date of injury? Still off work?
AM
M M / D D / YR PM AM PM Yes No Yes No
The following are the types of injuries that are considered OSHA recordable. A) A loss of consciousness, B) Fractures, C) Lacerations requiring a mechanical closure
like sutures or clips, D) Work-caused eye injuries treated by a physician and E) Any work restriction or physician-prescribed light work as a result of an injury.

Revised 02/03/05 Page 1 of 2

Attention: This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possible
while the information is being used for occupational safety and health purposes.
 Employee(s) giving First Aid on-site: (Include contractor’s company) Describe Treatment
Hospital/Clinic Treatment 1st Aid – On Site Treatment refused
No Treatment Required 1st Aid – Hospital / Clinic
Referred to Clinic / Hospital? Name of Clinic / Hospital Name of Physician or other HCP Was company required Drug Screen
Yes No Taken? Yes No N/A
Clinic/Hospital Street Address:
MEDICAL

Was employee treated in an emergency room? Yes No Was employee hospitalized overnight as an in-patient? Yes No

If Hospitalized, was employee’s family contacted? Transported to Clinic / Hospital by:

Yes No Taxi Another Employee Ambulance Self N/A
Did injured return to work? Were any restrictions given? Was any medication prescribed / Was a return visit scheduled?
Yes No Yes No given? Yes No Yes No
If employee returned to work on the SAME SCHEDULED Shift, was the clinic / hospital release verified? Yes No
Was OSHA notified (if applicable?) If notification required, write exact date, time, & name of person spoken to (note if message left on machine)
Yes No NA

Loss Potential Type of Event:

Severity: Major Serious Minor From SCAT Chart; Number Description
Probability: High Moderate Low
Frequency: Extensive Moderate Low See also check boxes below
Immediate/Direct Cause(s) Basic Root Cause(s)

From SCAT Chart; From SCAT Chart;

What other conditions may have contributed to the accident? (tools, equipment, machines, facilities, buildings, contractors, PPE)
ANALYSIS

Unsafe Practice: (check one)

Unauthorized Failure to use PPE/PPE Properly Using Defective Equipment Improper Position for the Task
Improper loading, piling, stocking Working on moving / running / equipment Operating at Improper Speed
Unsafe conditions created by:
Inadequate Guards/Barriers Inadequate/ Improper Protective Equipment Poor Housekeeping/Disorder Noise
Exposure
Defective Tool/Materials/Equipment Inadequate Illumination Inadequate Ventilation
JSA Not Used Hazard Not Identified
Was accident reviewed with Was job guide-lined by Were procedures Was employee following Do Procedures or Rules,
employee? specific job procedures? communicated in writing? these rules, instructions? need developed or revised?
Yes No Yes No Yes No NA Yes No NA Yes No

CORRECTIVE ACTION (S) TO PREVENT RECURRENCE Responsibility accepted by: Due Date
CORRECTIVE ACTION

SAFETY COMMENTS / RECOMMENDATION Acknowledgment Signature Date

JSA Required? Employee:
JSA Written By: Supervisor:
JSA Reviewed By: Department Mgr:
Safety Dept:
Safety Committee:
Plant Mgr:

Distribution: Original OSHA Site File; Workers Compensation Administrator ( State FROI Form )

Revised 02/03/05 Page 2 of 2

Attention: This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possible
while the information is being used for occupational safety and health purposes.