RF ASSESSORIA SEGURANA DO TRABALHO

E MEIO AMBIENTE
www.rfseg.com.br

FICHA DE ANALISE E INVESTIGAO DE ACIDENTES

COMISSAO INTERNA DE PREVENA DE ACIDENTES CIPA 2009/2010
EMPRESA: ___________________________________________________________________
ENDEREO: __________________________________________________________________
NOME DO ACIDENTADO: ________________________________________________________
IDADE:_____________ OCUPAO________________________________________________
SETOR: _______________________________ SEO: _______________________________
DIA: _______________________,

HORA: _____:_____,

DATA: ____/____/_______

PARTE DO COPO ATINGIDA: _____________________________________________________

FONTE DA LESO: _____________________________________________________________
NATUREZA DA LESO:__________________________________________________________
INFORMAES DO ENCARREGADO: _______________________________________________
____________________________________________________________________________
____________________________________________________________________________

INVESTIGAO DO ACIDENTE
COMO OCORREU:
________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
CAUSA APURADA: _______________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

CONCLUSES DA COMISSO
CAUSA DO ACIDENTE:__________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
RESPONSABILIDADE:___________________________________________________________
____________________________________________________________________________
MEDIDAS PROPOSTAS: _________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
___________________________________________________________________________
_

PRESIDENTE DA CIPA

VICE-PRESIDENTE CIPA

__________________, ____de ______________de 2008