accident investigation report form

Document Sample
accident investigation report form Powered By Docstoc
					                      COUNTY ACCIDENT INVESTIGATION REPORT
(Should be completed within 24 hours)

Instructions: This Accident Investigation Report is a tool for department supervisors and accident
investigation teams to find main causes of illnesses, injuries, and "near misses" and to take
corrective actions. Departments are strongly encouraged to use this form as a method of
reducing hazards in their areas.
Statement of Injured Employee Concerning Incident:




Employee Signature:
Department:
Date:



Witness Statement:




Witness Signature:
Department:
Date:



Equipment Involved

Name of Equipment

Manufacturer

Age of Equipment
Model & Serial #

Location
Was there an equipment failure?
Unsafe Acts or Conditions Involved in the Event (Walking Surfaces, Work Practices, Work Area Design,
Weather, Previous Incidents?




Corrective Action to be Taken : (Use separate paper for additional information)

Item #       Description                  Person                 Target Date         Date Completed
                                          Accountable




Example of Corrective Actions:

Re-design work environment         Improve housekeeping                Improve lighting
Reduce noise/vibration             Improve ventilation                 Improve inspection procedure
Re-train affected workers          Install safety/guard device         Use less hazardous materials
Use Personal Protective Equip.     Correct building hazards            Repair/replace equip. or tools


Investigation Reported/Completed By:
Signature:                                           Date:

Report Reviewed By:

Signature:                                           Date:

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:36
posted:9/13/2012
language:English
pages:2