Investigation Report for Workplace Injuries

1. Name of employee
2. Occupation
3. Date of incident Time
4. Place of incident
5. Witness(es)
6. Did you authorize first-aid or doctor? 00 Yes 00 No
Name and address of doctor
7. Did injured leave work? 00 Yes 00 No When
8. Did injured return to work? 00 Yes 00 No When
9. Describe nature and extent of injuries
10. Describe incident
11. Accident causes (mark those that apply)

Physical Sources Unsafe behaviors

00 Poorly maintained tools or equipment 00 Inadequate instructions

00 Poor housekeeping, slippery floor, or 00 Did not use assigned personal protective
tripping hazards equipment
00 Unguarded equipment 00 Did not follow rules or instructions
00 Crowded work conditions 00 Circumvented safety features
00 Used poorly maintained tools and machinery
00 Poor storage practices
00 Failed to follow established procedures and
00 Personal protection and clothing not
work practices
adequate for hazards
00 Unable to physically perform work
00 Insufficient lighting or ventilation 00 Other contributing behaviors
00 Cold or hot temperatures
00 Other contributing conditions

12. Describe actions to take to avoid recurrence:

13. Prepared By:

(Supervisor)
Reviewed By:
(Person Responsible for Safety)

(Manager)