Accident Investigation Form HR

Accident Investigation Form HR

Please submit this completed form to the HR Department for further review and investigation.

A. Incident Details

Incident Information

Date of Incident:

Time of Incident:

Location of Incident:

Incident Description:

B. Individuals Involved

Employee(s) and Witnesses Involved

Employee Name:

Job Title:

Employee ID:

Department:

Supervisor (if applicable):

Witness Name:

Phone:

Address:

C. Injuries and Damages

Injuries:

[Description of Injuries]

Property/Equipment Damage:

[Description of Damages]

D. Incident Causes

Identify the immediate causes of the incident. Check all that apply:

  • Slip/Trip/Fall

  • Unsafe Equipment/Tools

  • Inadequate Training

  • Hazardous Materials

  • Unsafe Acts/Behavior

  • Other (Specify):

Identify the underlying root causes that contributed to the incident. Check all that apply:

  • Lack of Safety Procedures

  • Inadequate Supervision

  • Poor Communication

  • Insufficient Personal Protective Equipment

  • Lack of Maintenance

  • Other (Specify):

E. Corrective Actions

Immediate Actions Taken

[List of Actions Taken]

Preventive Actions

[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:

HR Templates @ Template.net