Accident Investigation Form

If an accident ever occurs at the worksite, the immediate responsibility for the staff is to report it and for the management to start an investigation. Usually, an accident investigation form is filled up by the supervisor on shift by interviewing the staff and witnesses so that most information can be gathered. This form can later be used to investigate the cause of the accident.

Accident investigation

Home address:

Employee working since:

Type of injury

Photo :

Comments :

Equipment involved:

substances/chemical involved:

Accident description:

Cause of accident:

Name of organisation:

Department:

Date of accident:

Date the accident was reported

Time of accident:

Type of accident

Medical aid provided:

Name of injured person:

Department and designation:

Contact number:

Date of birth:

Accident severity: (minor/serious/very serious)

minor serious very serious

Likeliness of happening again (never/rare/occasional/often)

never rare occasional often

Suggested actions to be taken to avoid similar accidents:

Description:

Supervisor incharge for actions:

To be completed by:

Type of first aid:

First aid given by:

Name of doctor/hospital:

Has work safety advice been given?

Accident investigated by:

Signature:

SIGNATURE

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Accident Investigation Form

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