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Accident Investigation Report Please complete thoroughly and email to Desirée Mertz, HR. Note to Supervisor Remember that an accident investigation is not designed to find fault or blame. Rather, it is a tool to find causes that can be controlled or eliminated. Completing the Investigation Try to answer these questions: Who was injured? What materials, equipment, machines or other conditions were involved? Why did the accident happen? When did the accident happen? Where did it happen? How did the accident occur? Date: HR # (HR will complete): Employee/ Property Involved: Position: Date Employed: Supervisor: Department: How long has employee been in this job? Was the employee trained? Yes No Severity of Injury (HR will complete) OSHA Recordable? Yes First- aid only Medical treatment only Fatality Lost workday (away from work) Date lost time began: Date restricted time began: RTW date: Type of Injury Fall from elevation Fall on same level Struck against Struck by Puncture Caught in, under, or between Rubbed or abraded Bodily reaction Overexertion Contact w/ electrical current Contact w/ Temp. Extreme Contact w/ other Public transportation accident Motor vehicle accident Slip No Near Miss Restricted duty Unknown Other (describe below) Nature of Injury Abrasion Amputation Burn Contusion Crushed Foreign Body Fracture Inhalation Laceration Puncture Rash Strain Sprain Skin Contact Rep. Motion Illness/Infection Other (describe below) Face Finger Foot/feet Groin Hand Head Internal Organs Leg Multiple Neck Torso Trunk Wrist Other (describe below) Body Part Injured Arm Back Eye Details of injury (example: laceration of third finger on left hand): Date of accident: Date reported to supervisor: How did accident occur? Time of accident: Time employee began work: Cause of accident: Is there a policy pertinent to this accident? If so, what is it and was it followed? (i.e. lockout tagout, PPE, etc.) Witnesses Name: Dept./Address: Phone Number: Make Recommendations No accident investigation is complete unless corrective action is suggested and implemented. Recommendations to prevent a recurrence: What action has been taken or planned to date? Follow-up Determine and document what action has been taken on your recommendations. Supervisor’s Signature (initials if emailing): Employee’s Signature (initials if emailing): Safety Committee Comments Endorses actions indicated above Recommendations: Additional Comments: Diagram or Photo: Date: Date: Make new or additional recommendations