ACCIDENT INVESTIGATION FORM

OFFICE/SITE WORK AREA:

ACCIDENT TASK/ACTIVITY:
DESCRIPTION:

MANAGERS NAME: MANAGERS

SIGNATURE:

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 QUESTION/FACTOR REMARKS
1. DETAILS:
 Name of individual(s) involved

 Date of accident

 Time of accident

2. LOCATION
 What was the precise location of
accident within the unit?

2a. DIAGRAM/ SKETCH

 Draw a sketch of the accident
scene including measurements in
adjacent space provided.

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 QUESTION/FACTOR REMARKS
3. ACTIVITY
 What was the activity being
undertaken at the time of the
accident?
 If so, who was involved in this
activity?

4. DESCRIPTION OF ACCIDENT
 Provide a brief description the
accident

5. UNSAFE ACTS
 Was the accident caused by YES/NO
unsafe acts?
 If so, what were the unsafe acts?

6. UNSAFE CONDITIONS
 Was the accident caused by YES/NO
unsafe conditions?
 If so, what were the unsafe
conditions?

7. EQUIPMENT
 Was equipment involved in the YES/NO (if ‘NO’, go to Question 10)
accident?

 What equipment was involved in

the accident?

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 QUESTION/FACTOR REMARKS
8. EQUIPMENT CONDITION
 What was the condition of the
equipment?

 Were there any defects? YES/NO

 If so, what were they?

 Had any defect(s) been reported? YES/NO

(to who/when/any action taken
etc.)
 Are there records of examination YES/NO
or maintenance for the equipment
used?

9. EQUIPMENT TRAINING
 Was the injured person instructed YES/NO
and trained on the equipment
being used (using the equipment
training brief)?
10. STAFF INSTRUCTION/TRAINING
 Has the individual been given YES/NO
training/ instruction (including Safe
Systems of Work) appropriate to
the task they were performing at
the time of the accident?
 If so, is there a record of the
training/instruction?
11. MATERIALS/SUBSTANCES
 Were any materials or substances YES/NO
involved in the accident?
(Name and nature of any materials
or substances involved)

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 QUESTION/FACTOR REMARKS
12. ENVIRONMENT
Describe the environmental factors
at the place of the accident. For
example, consider the floor
conditions, lighting conditions,
ventilation, noise etc.
13. WITNESSES
 Were there any witnesses to the YES/NO (if ‘YES’, please attach the witness statements)
accident?

14. PREVIOUS HISTORY

 Have there been similar previous
occurrences?
 If so, what action had you taken to
prevent re-occurrence?
15. ANALYSIS
 What was the cause of the injury?

 What was the cause of the

accident?
16. WHY. . .
WHY. . .
WHY. . .
WHY. . .
WHY. . .
17. REMEDIAL ACTIONS
 What actions have been taken to
prevent a reoccurrence of the
accident?

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