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Use this template for an accident report to investigate accidents in detail. Analyze the causes of an accident or near-accident in the workplace. This digital form for the accident report is used by supervisors to collect facts about an incident.
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Include names and phone numbers of all witnesses to the incident. Attach witness statements.
What immediate causes, failures to act, and conditions contributed directly to the accident?
What basic causes are the contributing factors? (Job factors, personal factors)
What action or recommendations are to prevent recurrence? When? And action by?
Potential of Frequency
Severity of Incident
Costs of Incident
Please note that this checklist template is a hypothetical example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.
Please, finish the registration to access the content of the checklist.