Incident or Accident Investigation Sample Form

Name of organization: ___________________________________

PARTICULARS OF ACCIDENT
Date of accident
Mon  Tues  Wed  Thurs  Fri  Sat  Sun  (circle appropriate day)
Time    Location    Date reported

THE INJURED PERSON
Name
Address
Age
Phone number
Date of accident
Length of employment
Length of time on this job

TYPE OF INJURY
Strain/sprain
Fracture
Laceration/cut

Bruising
Scratch/abrasion
Amputation
Burn scald

Dislocation
Foreign body
Internal
Chemical reaction

Other (specify)

Remarks

Injured part of body (e.g., head, back, groin, leg, arm, wrist)

DAMAGED PROPERTY
Property/material damaged
Nature of damage
Object/substance inflicting damage

THE ACCIDENT
Description
Describe what happened (space on back for diagram \ essential for all vehicle accidents)

Analysis
What were the causes of the accident?

How bad could it have been?
Very serious    Serious     Minor

What is the chance of it happening again:
Minor    Occasional    Rare

Prevention
What action has or will be taken to prevent a recurrence?    By whom    When
Check off items already in effect.

TREATMENT AND INVESTIGATION OF ACCIDENT
Type of treatment given
Name of person giving first aid
Doctor/Hospital

Accident investigated by
Date
OSHA advised YES / NO
Date