ACCIDENT INVESTIGATION FORM (template)
[Pages:1]ACCIDENT INVESTIGATION FORM (template)
Name of organisation:
PARTICULARS OF ACCIDENT
Date:
Time:
DETAILS OF INJURED PERSON
Name:
Age:
Department: Location: Date of accident:
Date reported: Contact number:
Job title:
Address:
Length of employment:
Type of injury: Injured part of body:
DAMAGED PROPERTY Property damaged: Nature of damage:
THE ACCIDENT Describe what happened
WHAT WERE THE CAUSES OF THE ACCIDENT?
How bad could it have been? Very serious
Serious
What is the chance of it happening again? Frequent
Occasional
What has or will be done to prevent it occurring again in future?
Minor Rare
TREATMENT AND INVESTIGATION OF ACCIDENT
Type of treatment given:
Name of first aider:
Accident investigated by:
Date:
OSH advised?
Doctor/hospital: Date
................
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