Accident Investigation Form HR Template
save
save
copy
downloadDownload
save
save
save
copy
copy

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