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