Accident Investigation Report

Employer
Name:
Type of business:

Address:

Injured Employee
Last name:
Address:
Age:
Nature of injury:

First name:

Occupation:

Experience at work involved:

Accident / Injury
First aider:
Medical treatment:
Name and address of doctor:
Hospital:
Date and time of accident:
Project and location of accident:
Date and time accident reported to supervisor:
Date and time accident reported to MOL:
Name of MOL representative who took the call:
Date and time accident reported to head office:
Names and addresses of witnesses:
Background
Who made the work assignment?
Directions the employee received before starting work:
Were any specific procedures involved?
Yes
Description of machinery or equipment involved:

No

N/A

Accident Description
Explain what happened (what, where, when, who, how).
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Sketch / Diagram

Immediate Cause

Underlying Causes

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How can the accident be prevented from happening again?

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What steps have been taken to prevent a recurrence of the accident?

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Action By:

Report Prepared By: