Accident Investigation Form (Example 2)
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1Accident investigation form (example 2)
Use this form to help you investigate workplace accidents or incidents. Note: this form is for use within your company. It is not
intended to replace DCBS Form 801: Worker’s and Employer’s Report of Occupational Injury or Disease.)
Employee portion
Employee name:
Employee work phone:
Work unit:
Work section:
Supervisor name:
Supervisor work phone:
Length of service in present position:
Less than 6 months
6 months-1 year
1-2 years
2-3 years
3-5 years
More than 5 years
Exact location of accident/incident:
Accident/incident date:
Time:
a.m.
p.m.
Witnesses
Name:
Phone:
(
check if no witness)
Name:
Phone:
Body part affected
Neck
Shoulder(s)
Elbow(s)
Wrist(s)/hand(s)
(check all that apply)
Thigh(s)
Lower leg(s)
Ankle(s)/foot(feet)
Knee
Hip
Upper back
Lower back
Chest/abdomen
Other:
Task that led to the incident:
Driving
Lifting
Carrying
Pushing/pulling
Keyboarding
Climbing
Reaching
Handling
Bending
Twisting
Other:
Describe accident/incident in detail (use additional sheets if necessary):
Employee signature:
Date:
Supervisor portion
Reported to:
Date:
Time:
a.m.
p.m.
Supervisor’s description of incident (what happened and why):
Corrective action:
Employee signature:
Date:
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