Free Accident Investigation Form HR Template
Accident Investigation Form HR
Please submit this completed form to the HR Department for further review and investigation.
A. Incident Details
Incident Information
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Date of Incident: |
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Time of Incident: |
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Location of Incident: |
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Incident Description: |
B. Individuals Involved
Employee(s) and Witnesses Involved
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Employee Name: |
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Job Title: |
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Employee ID: |
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Department: |
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Supervisor (if applicable): |
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Witness Name: |
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Phone: |
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Address: |
C. Injuries and Damages
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Injuries: |
[Description of Injuries] |
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Property/Equipment Damage: |
[Description of Damages] |
D. Incident Causes
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Identify the immediate causes of the incident. Check all that apply: |
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Identify the underlying root causes that contributed to the incident. Check all that apply: |
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E. Corrective Actions
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Immediate Actions Taken |
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[List of Actions Taken] |
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Preventive Actions |
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[List of Preventive Actions] |
F. Reporting to Authorities
In accordance with local regulations, we have notified the Occupational Safety and Health Administration (OSHA) of this incident. The report was submitted on [Month, Day, Year]. Contact information for OSHA: [Contact Number].
G. Documentation and Signatures
Attachments
[List of Attached Documents]
Signatures
By signing below, you acknowledge that the information provided in this report is accurate to the best of your knowledge.
Prepared By: [Your Name]
Date: [Month, Day, Year]
Signature:
