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Accident Investigation Form \ Sample-2

To be sent to [Insert title or person, e.g., Safety Director, Safety anager, Safety !fficer,

"#air Safety "ommittee, $%ec&tive Director' (it#in )* days of t#e date of t#e accident

T#is side to be completed by t#e appropriate s&pervisor

Date of Accident+!cc&rrence Time

lace of Accident+!cc&rrence /ame of in0&red person1s 1if any

) 3as+(ere any ot#er person1s involved in, or (itness to, t#e accident4 If so give

employee1s name1s, titles, departments, p#one n&mbers5 if not an employee, record

name, company, p#one n&mber

2 3as+(ere t#e person1s involved appropriately trained and a&t#ori6ed4

7ive brief details of relevant training and a&t#ori6ation

8 Are t#ere any (ritten r&les or ot#er instr&ctions applicable to t#e (or94

If so give brief details

* 3as t#ere any apparent breac# of r&les or instr&ctions, or any apparent

malpractice4 If so, give details

: S&pervisor;s additional comments

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S&pervisor;s signat&re Date

age 2

A=!=IAT$ A/A7$= T! "!>$T$ A=TS

7/26/2019Accident Investigation Form

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B Cas t#e investigation identified any training need4 If so, give details

)? 3#at action #ave yo& ta9en in respect of t#is accident4

)) Do yo& see any need for preventative action o&tside yo&r department4 If so, give

details of t#e action and ot#er departments concerned

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anager;s signat&re Date

3#en complete, t#is form s#o&ld be sent immediately to [Insert title or person, e.g.,

Safety Director, Safety anager, Safety !fficer, "#air Safety "ommittee, $%ec&tiveDirector'