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Accident Investigation Form Template

This supervisor's accident investigation form provides details about a workplace injury. It documents the employee's name and job title, time with the company, accident date and time, location, and task being performed. The form describes the accident and injuries. It asks whether unsafe acts or conditions contributed and allows selecting multiple contributing factors. It inquires about prior similar incidents and has sections for a cause and effect diagram and 5 Whys root cause analysis. The form concludes by identifying the root cause, recommending corrective actions, assigning responsibility, and setting a completion date.

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Hayu Weka
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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204 views2 pages

Accident Investigation Form Template

This supervisor's accident investigation form provides details about a workplace injury. It documents the employee's name and job title, time with the company, accident date and time, location, and task being performed. The form describes the accident and injuries. It asks whether unsafe acts or conditions contributed and allows selecting multiple contributing factors. It inquires about prior similar incidents and has sections for a cause and effect diagram and 5 Whys root cause analysis. The form concludes by identifying the root cause, recommending corrective actions, assigning responsibility, and setting a completion date.

Uploaded by

Hayu Weka
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

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SUPERVISOR’S ACCIDENT INVESTIGATION FORM


Employee’s Name: Job Title:

Time employee has been in current position? How long had employee been at work prior to injury? Accident Date:
Choose an Item Choose an Item
Time of Accident: Overtime: Location of Accident (Be Specific):

☐ AM ☐ PM ☐ Yes ☐ No
Specific Task Being Performed at Time of Injury:

Description of Accident and the Injuries:

Was it unsafe acts that contributed to this incident? Were unsafe conditions that contributed to this incident?

☐ Yes ☐ No (If “Yes”, check all that apply below.) ☐ Yes ☐ No (If “Yes”, check all that apply below.)
☐ Lack of training or skill ☐ Inadequate guarding
☐ Lack of written procedure ☐ Unsafe equipment
☐ Distracted ☐ Defective equipment or tools
☐ Failure to anticipate ☐ Improper lighting
☐ Operating without proper authority ☐ Improper ventilation
☐ Disabled safety devices ☐ Unsafe position
☐ Working on moving equipment ☐ Weather Conditions Snow and Ice
☐ Poor housekeeping ☐ Uneven walking surface
☐ Operating at unsafe speeds ☐ Slippery walking surface
☐ Failure to lockout ☐ Other:
☐ Horseplay
☐ Unsafe lifting
☐ Improper dress
☐ Failure to use available equipment/tools
☐ Improper personal protective equipment (PPE)
☐ Other:
Have there been similar incidents or near misses prior to this? If “Yes”, explain:

☐ Yes ☐ No
To help determine cause, please complete one or both of the following root cause determination diagrams:

Cause and Effect Ishikawa Fishbone


People Machine

Problem/Effect

Process Materials Environment

Page 1 of 2

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SUPERVISOR’S ACCIDENT INVESTIGATION FORM

The 5 Whys

Why did the incident occur?


Why is
that?

Why is
that?

Why is
that?

Why is
that?

What is the Root Cause:

Recommended Corrective Action:

Responsible Party for Action: Date Complete:

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