Accident Investigation Report - CoAction Specialty

The unsafe acts of persons and the unsafe conditions that cause accidents can be corrected only when they are specifically known. You are responsible for immediately reporting unsafe working conditions and/or unsafe persons in the work area.

General Information

Name of injured: ______________________________________________________ Dept.: ______________________________________________________

Date of accident: _______________________ Time: ________ A.M. P.M.

Location of accident ______________________________________________________

Job or activity at time of accident: ____________________________________________

Accident Description

Describe the Accident:

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_______________________________________________________________________________________________________ _______________________________________________________________________________________________________

Names of witnesses:

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Cause of the Accident

Describe any unsafe actions:

Describe any unsafe conditions:

Describe any contributing causes:

_______________________________________________________________________________________________________

Corrective Action to be Taken:

Recommend what can be done and by whom to prevent the recurrence of a similar accident.

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Supervisor Signature: ______________________________ Date: ___________________