Accident Investigation Form \ Sample-1
Vehicular
Name of Injured Employee/Volunteer ______________________
Date of Accident ______________________________________
Job Title _____________________________________________
Time of Accident ______________________________________
Department __________________________________________
Location of Accident ___________________________________
Name of Witness(s) ____________________________________
Description of Accident _________________________________
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Task Being Performed __________________________________
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Equipment, Tools, Personal Protective Equipment, Procedures Being Used
_____________________________________________________
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Description of Injury/Illness (include accident type, injury type and body
part injured)
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Describe All Contributing Factors _________________________
Description of Work Area _______________________________
Injured Employee/Volunteer's Account of Accident __________
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Witness's Account of Accident: (Name, title, address, phone number)
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What Were the Basic Causes of the Accident (usually multiple causes)?
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Corrective Measures to be Implemented to Prevent Similar Reoccurrence
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Investigator's Name ___________________________________
Date of Investigation __________________________________
