ACCIDENT INVESTIGATION

COMPLETED FORM MUST BE FORWARDED TO CORPORATE SAFETY MANAGER WITHIN 10 WORKING DAYS
1. GENERAL DATA
Case No.
Employee name:
Social Security No.
Sex
Date of injury
Job Title
Office

Age
OT last week

Immediate Supervisor

Time of injury
Date injury reported

Location of injury (address, description of job site)

Date of hire

II. MEDICAL DATA

A. Class of injury (check one only)
B.

C..

Fatality
Lost workday
Nature of injury (check all that apply)
Amputation
Contusion, bruise
Asphyxiation
Cut, laceration
Burn, scald
Dermatitis
Burn, chemical
Dislocation
Concussion
Electric shock
Contagious infectious
electrocution
disease
Part of body affected (check all that apply)
Trunk (abdomen, back
Head and neck (eye, ear
chest, hips pelvis
face, mouth, scalp, skull,
shoulder, other)
neck, other)

III. ACCIDENT ANALYSIS

A. Accident type (check one only)
Struck by
Struck against
Fall from elevation
Fall to foot level
B.

C.

D.

E.

Motor vehicle accident

Public transportation
Rubbed or abraded
Bodily reaction

Source of injury (check all that apply)

Air pressure
Clothing, apparel, shoes
Animals, insects birds
Coal and petroleum
Reptiles
products
Animal products (not
Cold (atmospheric,
food)
environmental)
Body motion
Convey9rs, unpowered
Boilers, heating equip(chutes, rollers, etc.)
ment, pressure vessels
Dollies, hand trucks
Boxes barrels
Drugs and medicines
containers, packages
Electrical apparatus
Building and structures
Excavation, trenches
Ceramic items
tunnels
Chemicals (liquids,
Flame, fires, smoke
solids, gases, vapors,
fumes, etc
Unsafe act (check all that apply)
Horseplay
Working on energized
Failure to secure, warn
pressurized equipment
lockout, or assure
Misuse of equipment
clearance
tools, materials, vehicles
Improper lifting or
Driver/operator error
carrying
Failure to use equipment
Improper task selection
provided
Unsafe condition (check all that apply)
Poor housekeeping
Inadequate illumination
Inadequate traffic
Inadequate or improperly
traffic hazards
designed ventilation
Unstable design
Inadequate or improper
construction layout or
guarding
prescribed work method
Supervisory conditions (check all that apply)
Failure to enforce
Failure to follow
Safety rules, standards
instructions
or procedures
Incorrect job
Inadequate inspection of
assignment, layout
equipment or work
or design

No lost time

First aid only

Other

Flesh burn
Foreign body in eye
Fracture
Freezing, frostbite
Hearing loss or
impairment
Heat stroke, sunstroke

Hernia rupture
Poisoning-systemic
Pneumoconiosis
Radiation effects
Scratches, abrasions
Strains, sprains

Occupational disease
Other

Lower extremities
(ankle, foot, knee, lower
leg, thigh, toe, other)

Upper extremities
(upper arm, elbow
forearm, finger, hand
Wrist, other

Body system
(Circulatory, digestive,
genitourinary, nervous,
musculo-skeletal,
respiratory, other)

Overexertion
Contact with electric
current
Contact with temperature
extremes

Contact with chemical

or toxic substance
Exposure to physical
hazards (noise, UV
radiation)

Inhalation of toxic
substance
Other
Caught in, under or
between

Floors, level surface

Furniture, fixtures
furnishings
Glass items
Hand tools, unpowered
Heat (atmospheric,
environmental)
Hoisting apparatus
Infectious, parasitic
agents
Ladders scaffolds
Liquids

Machines
Mechanical power
transmission apparatus
Metal (plate, sheet, coil)
Noise, vibration
Paper, plastic, foil
Particulate (undefined)
Plants, trees vegetation
Plastic items
Pumps prime movers
Radiating substances
equipment

Soaps, detergents
cleaning compounds
Silicates
Scrap wastes, debris
Steam
Textile items
Tooling and fixtures
Vehicles, powered
Wood items (pulp,
lumber, slabs, chips)
Working surfaces
Work area environments
Other

Failure to follow
instructions
Failure to use proper
personal protection
Improper use of hands
or body parts
Using, Placing, mixing
loading

Operation or acting
with authorizations or
in unauthorized location
Taking an unsafe body
position or posture
(climbing, reaching,
stretching)
Failure to wear safe
personal attire

Inattention to footing or
surroundings
Using unsafe equpment
Removing or making
safety devices
inoperative
Other

Natural hazards (terrain

elements, etc.)
Hazardous conditions
Improper stacking
palletizing and banding

Unavailability of
required equipment or
devices
No hazardous conditions
Other

Guarding not
provided
Defects of machines
tools, materials,

Inadequate training or
instruction provided
Failure to provide
appropriate persona
protective equipment

Failure to provide
correct of safe tools
Ineffective immediate
supervision

Other

Unclassified, not
determined

DESCRIPTION OF ACCIDENT:
A. Names of witnesses.

B. How did the accident happen? (Give a brief description)

C. Why did accident occur ? (Explain more fully any unsafe acts/conditions which contributed to this accident.)

D. Was the person(s) involved in the accident aware of the safe procedures to complete the job? Describe.

E. What corrective action is to be, or has been taken to prevent a reoccurrence. Who is responsible for corrective action and when is the expected completion date?
Any disciplinary action taken or recommended (list and specify)?

Investigated by:

Date:

FOR LOST TIME INJURIES:

Reviewed by Project Manager

Date:

Office Manager Review

with Regional Manager

Date:

Reviewed by Safety Officer

Date:

with CEO:

Date:

Reviewed by Office Manager

Date:

Reviewed by Corporate Safety Manager

Date:
Copies to: Project Manager, Office Manager, Safety Officer, Corporate Safety Manager