Form Sd1305 - 5 - Fdjj Accident Investigation
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2SD 1305 - 5
FDJJ ACCIDENT INVESTIGATION FORM
Name of Injured Employee ________________________________________________________________________ Employee ID Number ______________________________
Age _________________________ Sex ______________________ Years of Service __________________________ Time at Present Job _______________________________
Job Title _________________________________Facility or Office____________________________________ Supervisor _______________________Shift_________________
I Date of Injury _____________________________________ Time ______________________________ Date Reported ________________________________________
Facility or Office Where Injured ___________________________ Exact Location
______________ Body Part Injured
______________ Type of Injury _______________
Describe accident (What happened). Use additional paper if necessary:_________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
Witnesses____________________________________________________________________________________________________________________________________
II.
First Aid Only
Yes [ ]
No [ ]
Doctor Visit Required:
Yes [ ]
No [ ]
Medical Provider Utilized:_______________________________________________________________________________________________________________________
III. Unsafe Acts:
Yes [ ]
No [ ]
Unsafe Conditions:
Yes [ ]
No [ ]
Description:__________________________________________________________
Description:__________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Why was unsafe act committed?__________________________________________
Why did unsafe condition exist?__________________________________________
____________________________________________________________________
____________________________________________________________________
IV. Based on the information provided above (unsafe acts/unsafe conditions) what actions (counter -measures) have been taken or recommended to management to prevent
reoccurrence?
____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
V.
Investigated By:_______________________________________________________Title/Dept.______________________________________________Date:____________
VI. Safety Administrator’s Comments:____________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
Follow-Up Action Taken:_______________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
Date:
Date:
Date:
Immediate Supervisor
Safety Administrator
Facility Superintendent/Manager
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Parent category: Business