| ______________________________________ |
| 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.) |