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SUPERVISOR’S ACCIDENT INVESTIGATION FORM

Employee’s Name: Job Title:

Time employee has been in current position? How long had employee been at work prior to injury? Accident Date:
Choose an Item Choose an Item
Time of Accident: Overtime: Location of Accident (Be Specific):

☐ AM ☐ PM ☐ Yes ☐ No
Specific Task Being Performed at Time of Injury:

Description of Accident and the Injuries:

Was it unsafe acts that contributed to this incident? Were unsafe conditions that contributed to this incident?

☐ Yes ☐ No (If “Yes”, check all that apply below.) ☐ Yes ☐ No (If “Yes”, check all that apply below.)
☐ Lack of training or skill ☐ Inadequate guarding
☐ Lack of written procedure ☐ Unsafe equipment
☐ Distracted ☐ Defective equipment or tools
☐ Failure to anticipate ☐ Improper lighting
☐ Operating without proper authority ☐ Improper ventilation
☐ Disabled safety devices ☐ Unsafe position
☐ Working on moving equipment ☐ Weather Conditions Snow and Ice
☐ Poor housekeeping ☐ Uneven walking surface
☐ Operating at unsafe speeds ☐ Slippery walking surface
☐ Failure to lockout ☐ Other:
☐ Horseplay
☐ Unsafe lifting
☐ Improper dress
☐ Failure to use available equipment/tools
☐ Improper personal protective equipment (PPE)
☐ Other:
Have there been similar incidents or near misses prior to this? If “Yes”, explain:

☐ Yes ☐ No
To help determine cause, please complete one or both of the following root cause determination diagrams:

Cause and Effect Ishikawa Fishbone

People Machine

Problem/Effect

Process Materials Environment

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SUPERVISOR’S ACCIDENT INVESTIGATION FORM

The 5 Whys

Why did the incident occur?

Why is
that?

Why is
that?

Why is
that?

Why is
that?

What is the Root Cause:

Recommended Corrective Action:

Responsible Party for Action: Date Complete:

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