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Accident Investigation Report Template

A structured template for conducting thorough investigations of workplace accidents, incidents, and near-misses to identify causes and prevent future occurrences.

Accident Investigation Report Template

by: audit-now
4.2

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About This Checklist

An Accident Investigation Report Template is a crucial tool for ensuring thorough and systematic analysis of workplace incidents. This comprehensive checklist guides investigators through the process of gathering essential information, identifying root causes, and developing effective preventive measures. By utilizing this template, organizations can improve their safety protocols, reduce the likelihood of future accidents, and demonstrate their commitment to maintaining a safe work environment. Implementing a standardized accident investigation process not only helps in legal compliance but also contributes to creating a culture of safety awareness among employees.

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Industry

Safety and Risk Management

Standard

OSHA Recordkeeping Requirements

Workspaces

Factory
Warehouse
Laboratory
Construction Sites
Office Buildings

Occupations

Safety Manager
Occupational Health Specialist
Risk Management Professional
Human Resources Manager
Operations Supervisor
1
What is the incident report number for this investigation?

Please enter the incident report number.

To track and reference the specific incident being investigated.
2
Was the root cause of the incident identified?
Identifying the root cause is essential for preventing future incidents.
3
How many days did it take to resolve the incident?
Measuring resolution time helps assess the effectiveness of the incident response.
Min: 0
Max: 365
4
What preventive measures have been implemented following the incident?

Please describe the preventive measures in detail.

Documenting preventive measures is crucial for ongoing safety management.
5
Was the incident reviewed for OSHA compliance?
Ensuring compliance with OSHA standards is vital for workplace safety.
6
What is the date of completion for the investigation?
Tracking the completion date helps in maintaining accurate records.
7
Was the incident reviewed by a safety officer?
Review by a safety officer ensures an objective assessment of the incident.
8
Have all relevant witness statements been collected?

Please specify if witness statements have been collected.

Collecting witness statements is essential for a comprehensive investigation.
9
What was the total cost incurred due to the incident?
Understanding the financial impact helps in assessing the significance of the incident.
Min: 0
Max: 1000000
10
Was safety training provided to employees after the incident?
Providing safety training is crucial to prevent future incidents.
11
Provide a summary of the incident analysis.

Please summarize the incident analysis.

A thorough analysis summary aids in understanding the incident's context and implications.
12
What was the date of the incident?
Recording the date of the incident is necessary for documentation purposes.
13
Are any follow-up actions required based on the investigation findings?
Identifying follow-up actions is essential for continuous improvement in safety practices.
14
Was the emergency protocol activated during the incident?
Knowing if the emergency protocol was activated is important for evaluating response effectiveness.
15
Please list the names of individuals who were injured in the incident.

Enter the names of all injured parties.

Documenting injured parties is critical for follow-up and reporting purposes.
16
Was the investigation conducted by a designated investigation team?
Ensuring a qualified team conducts the investigation enhances the reliability of findings.
17
Describe the environmental conditions at the time of the incident.

Provide details about the conditions (lighting, weather, etc.).

Understanding environmental factors can help identify contributing causes to the incident.
18
How many safety violations were identified during the investigation?
Tracking the number of violations helps assess compliance and identify areas for improvement.
Min: 0
Max: 100
19
When was the safety review meeting held to discuss the incident?
Documenting the review meeting date is essential for tracking follow-up actions.
20
Has the insurance provider been notified about the incident?
Notifying the insurance company is important for processing claims and liabilities.
21
Was management informed about the incident and its findings?
Keeping management informed is crucial for oversight and decision-making regarding safety improvements.
22
Please provide a detailed description of the accident.

Include all relevant details about the accident.

A comprehensive description is vital for understanding the incident and its context.
23
At what hour did the incident occur?
Recording the time helps in analyzing incident patterns and safety measures.
Min: 0
Max: 24
24
Did the injured parties require medical attention?
Determining the need for medical attention is crucial for follow-up and support.
25
Were all required safety gear and equipment worn during the incident?
Assessing the usage of safety gear helps in understanding compliance with safety protocols.
26
When was the incident reported?
Documenting the reporting date is essential for tracking the investigation timeline.
27
Have corrective actions been implemented to prevent future incidents?
Implementing corrective actions is essential for improving workplace safety.
28
Please provide any follow-up recommendations based on the investigation findings.

List any suggested follow-up actions.

Recommendations are important for continuous improvement in safety practices.
29
What equipment was involved in the incident?

List all equipment involved in the incident.

Identifying the equipment involved helps in understanding the context and potential hazards.
30
On a scale from 1 to 10, how severe were the injuries sustained?
Assessing the severity of injuries is crucial for evaluating the impact of the incident.
Min: 1
Max: 10
31
Was the incident related to a violation of safety regulations?
Understanding compliance issues can help prevent similar incidents in the future.
32
Was appropriate personal protective equipment available at the time of the incident?
Availability of PPE is critical for ensuring worker safety.
33
When was the last safety training conducted before the incident?
Tracking safety training dates helps assess the need for improved training frequency.
34
Has an action plan been developed following the investigation?
Creating an action plan is essential for addressing the findings of the investigation.
35
What lessons were learned from this incident?

Provide a summary of lessons learned.

Documenting lessons learned is important for improving future safety practices.

FAQs

This template should be used immediately following any workplace accident, incident, or near-miss event to ensure all relevant information is captured while it's still fresh.

Typically, a designated safety officer, supervisor, or trained investigator is responsible for completing the report, often in collaboration with witnesses and involved parties.

The report should include details such as the date, time, and location of the incident, involved parties, witness statements, description of the event, immediate and root causes, and recommended corrective actions.

By systematically analyzing accidents, the template helps identify trends, underlying causes, and areas for improvement in safety protocols, leading to more effective preventive measures and a safer work environment.

Yes, while the core elements remain consistent, the template can be customized to include industry-specific factors, hazards, and regulatory requirements relevant to the particular workplace.

Benefits of Accident Investigation Report Template

Ensures a systematic and thorough approach to accident investigations

Helps identify root causes and contributing factors to prevent future incidents

Facilitates consistent reporting and documentation of accidents across the organization

Supports compliance with safety regulations and standards

Aids in developing effective corrective actions and safety improvements