SAMPLE ACCIDENT INVESTIGATION REPORT
Number _________ Date _________
Prepared by ________________________ ____________________________
SECTION I. BACKGROUND
Victim: _________________________________________
Witnesses (1) ___________ Address ________________ Phone (H) _________ (W) ____________
Job Title ______________ Length of Service ______
Witnesses (2) ___________ Address ________________ Phone (H) _________ (W) ____________
Job Title ______________ Length of Service ______
Accident Date _____________ Time of Accident_____________ Work shift __________________
Date Accident Reported ______________ Time Accident Reported___________(a.m./p.pm)
WHERE Department ________________ Location ____________________ Equipment __________
SECTION II. DESCRIPTION OF THE ACCIDENT (Describe the sequence of relevant events prior to, during, and
immediately after the accident. Attach separate page if necessary)
Events prior to: _____________________________________________________________________
Injury event: _____________________________________________________________________
Events after: _____________________________________________________________________
SECTION III. FINDINGS AND JUSTIFICATIONS (Attach separate page if necessary)
Surface Cause(s) (Unsafe conditions and/or behaviors at any level of the organization)
___________________________________________________________________________
Justification: (Describe evidence or proof that substantiates your finding.)
___________________________________________________________________________
Root Cause(s) (Missing/inadequate Programs, Plans, Policies, Processes, Procedures)
___________________________________________________________________________
Justification: (Describe evidence or proof that substantiates your finding.)
___________________________________________________________________________
SECTION IV. RECOMMENDATIONS AND RESULTS (Attach separate page if necessary)
Corrective actions. (To eliminate or reduce the hazardous conditions/unsafe behaviors that directly
caused the accident)
___________________________________________________________________________
Results. (Describe the intended results and positive impact of the change.)
___________________________________________________________________________
System improvements. (To revise and improve the programs, plans, policies, processes, and procedures that
indirectly caused/allowed the hazardous conditions/unsafe behaviors.)
___________________________________________________________________________
Results. (Describe the intended results and positive impact of the change.)
___________________________________________________________________________
SECTION V. SUMMARY (Estimate costs of accident. Required investment and future benefits of corrective actions)
___________________________________________________________________________
SECTION VI: REVIEW AND FOLLOW-UP ACTION (Describe equipment/machinery repaired, training conducted,
etc. Describe system components developed/revised. Indicate persons responsible for monitoring quality of the change.
Indicate review official.)
Corrective Actions Taken: Responsible Individual: Date Closed:
______________________________ ______________________ ____________
______________________________ ______________________ ____________
System improvements made: Responsible Individual: Date Closed:
______________________________ ______________________ ____________
______________________________ ______________________ ____________
Person(s) monitoring status of follow-up actions: ________________________________
Reviewed by ___________________ Title _______________________
Date ____________ Department _______________________________
SECTION VII. ATTACHMENTS (Photos, sketches, interview notes, etc.)
