Accident/incident Investigation Report (Page 2 of 3) in pdf

Accident/incident Investigation Report Page 2

DESCRIBE HOW THE ACCIDENT/INCIDENT OCCURRED.

ACCIDENT SEQUENCE: Describe in reverse order of occurrence events preceding the injury and accident. Starting with the injury and moving

backward in time, reconstruct the sequence of events that led to the injury.

A. Injury Event __________________________________________________________________________________________________________

B. Accident Event _______________________________________________________________________________________________________

C. Preceding Event #1 ____________________________________________________________________________________________________

D. Preceding Event #2. #3. etc. _____________________________________________________________________________________________

CASUAL FACTORS. Events and conditions that contributed to the accident. Be sure and describe in detail if the proper safety equipment was

being used and if it was used correctly.

CORRECTIVE ACTIONS. Those that have been, or will be, taken to prevent recurrence.

Investigation Ofﬁcer __________________________________________

Interpreter ______________________________________________

Company ____________________________________________________

Company _______________________________________________

Signature

Date

Signature

Date

Sample accident/incident investigation report

Accident/incident Investigation Report Page 2