Appendix I

INTERNAL ACCIDENT INVESTIGATION FORM

This form is an internal accident investigation document meant to facilitate, change, and improve the work environment for your employees. The investigation process is not fault finding and should not be used as an impetus for disciplinary action.

These steps will help you investigate an accident and fill out the form:

Discuss the accident with the employee involved and with any witnesses. Be sure to question the why ~ what ~ where ~ when ~ who ~ how aspects of the accident.
Inspect the equipment or materials involved for conditions that could be made safer.
Study the job set-up and process of doing work. Could it be improved?
Is the employee involved suited for the job he/she is doing? Did he/she receive adequate training? Are there any other contributing factors/problems? (i.e. use of drugs or alcohol, or emotional problems)
Recommendations to correct the problem must be practical. Be sure your recommendations will not create other situations, which could result in injury to employees.
Use the form to organize information gathered from your observations and interviews.
Complete your investigation report no later than the next working day after the accident.

Accidents Don’t Have to Happen!

ACCIDENT INVESTIGATION FORM

Employee Involved _________________________________________ Dept. ______

Employee # _______________ Employment Status P/T F/T Temporary Shift ___

Date of Accident ___/___/___ Time _____am or pm Location ______________

Job ________________________ Activity at Time of Accident ___________________

DESCRIPTION OF ACCIDENT: What happened at the time of the accident?

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Witnesses: ____________________________________________________________________

WHAT WAS THE CAUSE OF THE ACCIDENT?

Determine the cause by analyzing all the contributing factors if either a person, machine, or other physical condition was involved. Find out HOW and WHY.

Use the form to organize information gathered from your observations and interviews.

A. Describe any UNSAFE acts:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

B. Describe any UNSAFE conditions:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

C. Describe the FUNDAMENTAL ACCIDENT CAUSE:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

WHAT CORRECTIVE ACTIONS WILL BE TAKEN?

What have you done or what do you recommend to change or modify to prevent recurrence of a similar accident?

Has it been done? Yes No If Not, Why? (Explain)

______________________________________________________________________________