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Supervisor’s Incident Investigation Report(Sample #1)<br />for Workplace Injuries<br />1.Name of employee  Age  <br />2.Oc...
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Accident Investigation Report - Sample 1

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Accident Investigation Report - Sample 1

  1. 1. Supervisor’s Incident Investigation Report(Sample #1)<br />for Workplace Injuries<br />1.Name of employee Age <br />2.Occupation Dept. & No. <br />3.Date of incident Time A.M. P.M. <br />4.Place of incident <br />5.Witness(es) <br />6.Did you authorize first-aid or doctor?symbol 48 f " Typographic Ext" s 110 Yessymbol 48 f " Typographic Ext" s 110 No<br />Name and address of doctor <br />7.Did injured leave work?symbol 48 f " Typographic Ext" s 110 Yessymbol 48 f " Typographic Ext" s 110 NoWhen <br />8.Did injured return to work?symbol 48 f " Typographic Ext" s 110 Yessymbol 48 f " Typographic Ext" s 110 NoWhen <br />9.Describe nature and extent of injuries <br />10.Describe incident <br />11.Accident causes (mark those that apply)<br />Physical Sources<br />symbol 48 f " Typographic Ext" s 110Poorly maintained tools or equipment<br />symbol 48 f " Typographic Ext" s 110Poor housekeeping, slippery floor, or tripping hazards<br />symbol 48 f " Typographic Ext" s 110Unguarded equipment<br />symbol 48 f " Typographic Ext" s 110Crowded work conditions<br />symbol 48 f " Typographic Ext" s 110Poor storage practices<br />symbol 48 f " Typographic Ext" s 110Personal protection and clothing not adequate for hazards<br />symbol 48 f " Typographic Ext" s 110Insufficient lighting or ventilation<br />symbol 48 f " Typographic Ext" s 110Cold or hot temperatures<br />symbol 48 f " Typographic Ext" s 110Other contributing conditions<br />Unsafe behaviors<br />0Inadequate instructions<br />0Did not use assigned personal protective equipment<br />0Did not follow rules or instructions <br />0Circumvented safety features<br />0Used poorly maintained tools and machinery<br />0Failed to follow established procedures and work practices<br />0Unable to physically perform work<br />0Other contributing behaviors<br />12.Describe actions to take to avoid recurrence: <br />13.Signatures:<br />14.Prepared By:<br />(Supervisor)<br />Reviewed By:<br />(Person Responsible for Safety)<br />(Manager)<br />Date:<br />(Must be completed within 24 hours of incident)<br />- Company Use Only -<br />

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