Accident/incident Investigation Report
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3ACCIDENT / INCIDENT INVESTIGATION REPORT
COMPANY: _________________________________
DATE: __________________________________
ADDRESS: ________________________________________________________________________________
JOBSITE NAME: ___________________________________________________________________________
ADDRESS: ________________________________________________________________________________
NAME OF INJURED
DATE OF
TIME OF ACCIDENT/INCIDENT
ACCIDENT/INCIDENT
HOME ADDRESS AND PHONE
EMPLOYEE’S USUAL
OCCUPATION AT TIME OF ACCIDENT/
OCCUPATION
INCIDENT
EMPLOYMENT CATEGORY
LENGTH OF EMPLOYMENT
TIME in OCCUPATION
Regular, full-time
Seasonal
Temporary
Less than 1 mo.
6 mos. to 5 yrs.
Less than 1 mo.
6 mos. to 5 yrs.
Regular, part-time
Nonemployee
1–5 mos.
> 5 years
1–5 mos.
> 5 years
NAMES OF OTHER INJURED IN SAME ACCIDENT/INCIDENT
NATURE of INJURY and PART of BODY
TIME of INJURY
SEVERITY of INJURY
A.M/P.M
Fatality
A. ________________
Medical Treatment
B. Time within shift
First Aid
Other, specify ______________
C. Type of Shift
TASK and ACTIVITY at TIME of ACCIDENT/INCIDENT
SUPERVISION at TIME of ACCIDENT/INCIDENT
A. General type of task
Directly Supervised
Not Supervised
B. Specific Activity
C. Employee was working:
Alone
With crew or fellow worker
Indirectly Supervised
Supervision not feasible
Other, specify
LOCATION OF ACCIDENT/ INCIDENT
PHASE OF EMPLOYEES WORKDAY AT
WEATHER CONDITIONS AT
TIME OF ACCIDENT/INCIDENT
TIME OF ACCIDENT/INCIDENT
During rest period
Performing work duties
During meal period
Entering worksite
Working overtime
Leaving worksite
Other, specify _______________________
Yes
No
ON EMPLOYER’S PREMISES?
NAMES OF WITNESS TO THE ACCIDENT/INCIDENT
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Parent category: Business