Accident Investigation Form

Accident Investigation Form

Seeking Medical Treatment
Injured Employee Information
1. Name of Employee*
2.Date of Birth*

MonthDayYear
Date
3. SSN*
4. Employee Gender*
5. Phone*
6. Address*
7. Employee File # / Clock In ID*
8. Job Title*
9. Home Location
10. Date Hired
11. Department*
12. Employment Status
11. Department
2. Home Location
Accident Information
1. Date of Accident

MonthDayYear
Date
2. Time of Accident
3. Accident Location (if off premise please also indicate address)
4. Date Reported

MonthDayYear
Date
5. Witness(es)
14. Treatment
Was Employee sent to a Medical Facility?

YesNo
6a. If yes, please provide name and address of facility
6b. How did employee get transported to Medical Facility
15. Clock In Time
16. Time of Event
Injury Information
1. Severity Potential

HighMediumLow
2. Did Injury Result in Loss of Life

YesNo
3. Was the Injury work related?

YesNo
4. Did/Will Employee miss at least one full day of work after the incident?

YesNo
21. Type of Injury (Please Check All That Apply)

Contusion/CrushBurnDislocationSlipLacerationSuperficial BurnForeign BodyInternal InjuryConcussionSprain/StrainFractureFall
6.Location of Injury (Please Check All That Apply)

Head/FaceEyeInternal OrgansBackHand/FingersShoulder/ArmTrunkFoot/ToesHip/LegOther (State)
7. Briefly describe how injury occurred:
8. What Caused the injury (object/source)
9. Were there any contributing factors that caused the injury:
10. What could be done to prevent future accidents:
17. Severity Potential
19.Person Treating Injury (Physician/Hospital name and address)
20. Did the Injury result in lost time?
Light Duty Required?
Other Information
1. What was the employee doing just before the incident occurred?
2. Was there any Property damage?

YesNo
2a. If yes, please describe damage?
RK Employee Written Statement
Please provide a full written statement of how the accident happened:
Witness Name:
Witness Contact:
Witness Name:
Witness Contact:
Witness Name:
Witness Contact:
Signatures
Printed Name of Supervisor Completing Form
Date

MonthDayYear
Date
Signature of Supervisor

Clear
RK Employee Printed Name
Signature of Employee/Injured Party

Clear
Date

MonthDayYear
Date
26.Nature of damage?
Description (Describe what happened, who was involved, where, when, why, how)
28. Cause (Identify unsafe acts or conditions – contributing factors, base cause, lack of control)
29. Correction (describe steps taken to prevent future accidents)
30. Witness (any witnesses to the accident)
Follow Up (Pending a copy of the report)
31.Timeline
Activity (list of actions taken and dates)
Should be Empty:

Injured Employee Information

Accident Information

Injury Information

Other Information

RK Employee Written Statement

Signatures