• Accident Investigation Report
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• Directions for Completing the Accident Investigation Report

Accident Investigation Report

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Back of Accident Investigation Report

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Directions for Completing the Accident Investigation Report

Case Number - Will be assigned by safety coordinator
Facility - Facility name
Address - Street address
Department - Such as maintenance shop, kitchen, etc.
Location - Needed only if different from 'address'

1. Name of Injured - Last name first, first name, middle initial
2. Social Security Number
3. Sex - Check Male or Female
4. Age - At last birthday
5. Date of Accident - If illness give date of diagnosis
6. Home Address - Of injured party
7. Employee's Usual Occupation - ie. Clerk, lathe operator, mechanic, etc.
8. Occupation at Time of Accident - May be the same as #7, if not describe in the same way as #7.
9. Length of Employement - Check the appropriate box.
10. Time in Occupation at the Time of Accident - Check the appropriate box.
11. Employment Category - Check the appropriate box.
12. Case Numbers and Names of Others Injured in Same Accident
13. Nature of Injury and Part of Body - If injury, name body part, include right or left. If illness, name illness.
14. Name and Address of Physician
15. Name and Address of Hospital
     a. Time of Injury - Within 15 minutes
     b. Time within Shift - Indicate the hour in shift
     c.  Type of Shift - ie. Rotating or straight
16. Severity of Injury - Check the appropriate box.
17. Specific Location of Accident - ie. Loading dock #4, B-coal mill, etc.
18. Phase of Employee's Workday - Time of Accident - Check appropriate box.
19. Describe how the Accident Occurred - Provide a complete description of what happened including only facts, do not include opinions or blame.
     - what the injured and others involved in the accident were doing prior to the incident,
     - what relevant events preceded the accident,
     - what objects or substances were involved,
     - how the injury occurred and the specific object that caused the injury,
     - what, if anything happened after the accident.
20. Accident Sequence - Provide a breakdown of the sequence of event which lead to the accident.
     a. The accident event is the failure of equipment - describe what and how the equipment failed. For example, a steam line that breaks.
     b.  The injury event is what causes the damage to the employee - describe what caused the injury. For example, steam burning the arm.
     c.  Preceding event #1 - The last event which caused the accident event.
     d.  Preceding event #2, #3, etc. - The events which lead up to preceding event #1. Include only events which must have happened for the accident event to occur.
21. Task and Activity at the Time of Accident
     a.  Describe the task (ie, pipe fitting, operating a press, etc.) the employee was doing when the accident occurred.
     b.  Describe the activity (ie, removing a pipe, removing material from a press, etc.) the employee was doing when the accident occurred.
     c.  Check the appropriate box.
22. Posture of Employee - Describe the posture at the time of the accident, ie. standing on a ladder, reaching over a machine, squatting under a conveyor, etc.
23. Supervisor at Time of Accident - Check the appropriate box.
24. Casual Factors
25. Corrective Actions

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