ACCIDENT INVESTIGATION REPORT TEMPLATE

Use this Accident investigation report template to determine the root cause of the accident to prevent future incidents. This template can be used by workplace supervisors to record accurate information. Follow the points below to utilize this template:

1. Gather the general information of the harmed employee
2. Identify the details of the event
3. Explain the consequences of that accident
4. Gather witness/es statements if appropriate
5. Suggest precautions to avoid accident reoccurrence

General Information

Attach photo of Identification: ADD PHOTO

Date and time of the accident: SELECT DATE AND TIME

Location:

Are there other people involved?

NoYes

Accident Report

Write down all the details of the incident:

Photo evidence: ADD PHOTO

Cause:

Poorly maintained tools or equipment

Poor housekeeping, slippery floor, or tripping hazards

Unguarded equipment

Crowded work condition

Poor storage practicesFailure to wear PPE

Insufficient lighting or ventilation

Cold or hot temperatureOthers

Explain the injuries:

Did the worker need to leave work?

No/Yes

What are the consequences of the accident?

Personal injury

Property loss

Medical expenses

Decreased employee moral

Lost income

Lowered productivity

Other

Witness/es

Are there any witness/es?

Yes/No

Completion

How can the accident recurrence be avoided?

Full name and signature of the supervisor: