______________________________________
Project Name

 

 

 

ACCIDENT/INCIDENT INVESTIGATION

REPORT

 

 

FOR OFFICIAL USE ONLY

 

This document contains privileged, limited-use safety and privacy act protected information.  Unauthorized use or disclosure can subject you to criminal prosecution, termination of employment, civil liability, or other adverse actions.

 

 

 

 

Project Name: Project Location:
Completed By: Date: Accident Date: Time:
 

Personal Injury

Property Damage

Name: Property Damaged:
Employee#: Hire Date: Nature of Damage:
Performing Regular Job:
Type of Injury:
Nature of Injury:
Part of Body Injured:

 

Description of Accident:  (What occurred?  Include photos and diagram.)
 
 
 
 

 

Cause of Accident:  (How and why did it occur. Documentation to support training.)
 
 
 
 

 

Witnesses:  (Anyone who may have seen the accident occurred. Name, company, phone#)
 
 
 
 

 

Corrective Actions:  (Actions taken to prevent recurrence.)