Accident Investigation Report Employment Injury Department Orange Walk Branch Office SOCIAL SECURITY BOARD

SECTION 1 PARTICULARS OF INJURED PERSON

Submitted to : Submitted by: Date submitted:

Print Report
SSN.

Name of insured person: Address: Period of employment: SECTION 2 Date of accident: SECTION 3 Date of birth:

Occupation: Age:

Gender:

PARTICULARS OF THE ACCIDENT & INJURY Time of accident: Hours worked for the day:

DETAILS OF THE ACCIDENT GIVEN BY THE INJURED PERSON

Fully describe the accident. (when, where and how the accident occurred)

Are you trained to do the work process that you were performing when your were injured? To the best of your knowledge, why did the accident occur?

Do you believe that your work related injury could have been prevented? If your answer is YES, what corrective measures must be taken to prevent future similar accidents?

SECTION 4 Name:

DETAILS OF ACCIDENT GIVEN BY WITNESS Address: Occupation:

To the best of your knowledge, explain how the accident occurred. What injuries did you observe on the injured person? Do you believe that the accident could have been prevented? If yes, how?

SECTION 5

TO BE COMPLETED BY THE EMPLOYER OF THE INJURED PERSON (A supervisor represents the employer) Explain the basic cause of the accident (eg. unsafe behavior, unsafe workplace condition, equipment malfunction etc.) What corrective actions will be taken so that a similar accident is not repeated?

Please provide a detailed description of the accident. What training or experience does your worker has on the job being done when injured? Corrective action will be completed by this date: Name and signature of employer (supervisor)

Date:

FOR OFFICIAL USE ONLY SECTION 6 TO BE COMPLETED BY INVESTIGATOR OF THE SOCIAL SECURITY BOARD (Respond based on facts collected during your investigation)

Does the injured person has a Social Security card that is valid for employment? If foreigner, is worker engaged in work as stated in the Temporary Work Permit? Explain how the accident occurred and what injuries resulted. Does the employer keeps an accident record? What other source of information did you seek to verify that claim is a legitimate employment injury? Did the injury arise out of and in the course of insurable employment? Please explain Was the accident reported on time? 48 hours regular worker and 24 hours self employed VERIFIED salaries, 4 weeks prior to week of accident WEEK 1 WEEK 3 Corrective action that was recommended. WEEK 2 WEEK 4

What is the accident causation?

Does the accident cause requires issuing an OSH letter? If yes, please attach 4 copies of letter Does this claim requires further follow up for implementation of OSH action? Date: