Fillable m I Accident Investigation Form (Ursinus College)

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m I Accident Investigation Form (Ursinus College)

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m
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I I I I
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Accident Investigation Form
A. Employee Data
Claim # (if known):
Date of accident:
Time:
A.M P.M.
Employee Name:
Working Title:
Dept.
Employee Contact #:
Hm.
Wk.
Other
Supervisor Contact:
Wk
Page 1 of 3
May 2016
m
Accident Investigation Form
Signature of Accident Investigator
Date
Time
Returned completed form to the Environmental Health & Safety/Risk Manager.
Maintain one copy in any retrievable format in the site file for a minimum of 3 years.
Note: Employee medical and exposure records must be maintained for the duration of employment plus 30.
Note: If a workers’ compensation claim is filed, send to Human Resources, Corson Hall.
Page 2 of 3
May 2016
m
Accident Investigation Form
Instructions
Purpose of Form:
Effective loss control efforts require documentation of accidents to determine hazards or problem
areas, procedures, or systems and to perform trending. Thorough investigation is required to
determine the facts surrounding events so that remedial action can be taken, if required. This from
provides an outline of needed information.
Filing Deadline:
If the accident resulted in the filing of a workers’ compensation claim, the form must be received
by Environmental Health and Safety/Risk Manager no later than the 7th calendar day after the
filing of the worker’s compensation form.
Completed by:
A. Employee Data
Complete the top of the form with the identifying information and the date and time of the accident. If a claim
has been filed, complete the space for the claim number.
B. Accident Description
Attachment 1 contains benchmarked accident investigation procedures. Sufficient action is necessary to
ensure that all facts surrounding the accident are obtained so that effective loss control procedures can be
established to protect against future accidents occurring. The form is developed to capture this information and
to help the accident investigator come to reasonable conclusions concerning the events.
1.
Where did the accident happen and who was involved? Go to the scene. Provide a visual image of the
location of the accident. The reader should be able to visualize the area and the surrounding
environment. Include names of the people involved and interviewed.
2.
What was happening at the time of the accident and why was it taking place? Document the sequence of
events leading up to the accident. Include the activities surrounding the event and their purpose.
3.
What exactly caused the injury and how did it happen? What were the mechanics that caused the injury
or could have caused an injury? Were procedures followed? Are the procedures faulty? Was equipment
in good repair? Were there environmental hazards?
4.
Describe any injury incurred, body parts and kinds of injuries. Through interview with the affected
employee, determine what kinds of injuries were sustained and what body parts were involved. If an
injury was avoided, what could have caused an injury?
C. Investigation Results
After review of all facts, what was the hazardous condition, unsafe work practice or other root cause of
the accident/ injury?
D. Corrective Action
What is recommended to help prevent this type of accident from occurring again? Provide short term
and long term corrective actions that will prevent or eliminate the hazardous condition, unsafe work
practice, and root causes.
Who will be contacted concerning recommended action to ensure follow-up? Completion of this section
ensures that the management staff involved knows that action has been taken to remedy the hazardous
condition.
Page 3 of 3
May 2016
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Completed 24 July 2020

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