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ACCIDENT INVESTIGATION FORM
Name of organisation
*
PARTICULARS OF ACCIDENT
Date of accident
*
MM
DD
YYYY
Location of accident
*
Date reported
*
MM
DD
YYYY
The Injured person
Name
*
First Name
Last Name
Address
*
Date of birth
*
MM
DD
YYYY
Phone number
*
Type of injury
Bruising
Dislocation
Strain/sprain
Scratch/abrasion
Internal
Fracture
Amputation
Foreign body
Laceration/cut
Burn/scald
Chemical reaction
Other - enter in comments below
Comments:
Damaged Property
Property or material damaged:
Nature of damage:
Object/substance causing damage:
The Accident
Description:
*
Analysis:
*
How serious could it have been?
Minor
Serious
Very Serious
How often is this likely to happen again?
Never
Rarely
Occasionally
Often
Prevention:
What action has been taken to ensure it doesn't happen again?
What, by whom, and when?
What, by whom, and when?
What, by whom, and when?
Treatment and Investigation
Type of treatment given:
Name of person giving first aid:
Doctor / A&E / Hospital:
Accident investigated by:
Date
MM
DD
YYYY
Worksafe advised:
Yes
No
Date
MM
DD
YYYY
Thank you!
