Accident Investigation Report
Accident Investigation Report
Accident Investigation Report
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<strong>Accident</strong> <strong>Investigation</strong> <strong>Report</strong>Use with 296-800-320 <strong>Accident</strong>s and Incidents, Investigating and <strong>Report</strong>ingThis sample report form can help document the findings of a preliminary investigationinto an accident or incident in your workplace. You can copy and use this form ormake your own. Fill out an investigation report as soon as possible after an accidentor incident.Employee(s) name(s):Time & date of accident/incident:Job title(s) and department(s):Supervisor/lead person:Witnesses:Brief description of the accident or incident:Indicate body part affected:Did the injured employee(s) see a doctor?( ) Yes ( ) Noh t t p : / / w w w . l n i . w a . g o v /R-311/03
<strong>Accident</strong> <strong>Investigation</strong> <strong>Report</strong>Use with 296-800-320 <strong>Accident</strong>s and Incidents, Investigating and <strong>Report</strong>ingIf yes, did you file an employer’s portion of a worker’scompensation form?Did the injured employee(s) go home during their work shift?( ) Yes ( ) No( ) Yes ( ) NoIf yes, list the date and time injured employee(s) left job(s):Supervisor’s Comments:What could have been done to prevent this accident/incident?Have the unsafe conditions been corrected?( ) Yes ( ) NoIf yes, what has been done?If no, what needs to be done?Employer or Supervisor’s signature:Date:Additional comments/notes:R-411/031 • 8 0 0 • 4 B E S A F E ( 1 • 8 0 0 • 4 2 3 • 7 2 3 3 )
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