Name of Injured Employee ______________________
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's Account of Accident __________
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Witness’s Account of Accident: (Name, title, address, phone number) _____________________________________________________
What Were the Basic Causes of the Accident (usually multiple causes)?
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Corrective Measures to be Implemented to Prevent Similar Reoccurrence _____________________________________________________
Investigator’s Name ___________________________________
Date of Investigation __________________________________