SUPERVISORS ACCIDENT INVESTIGATION REPORT
NAME OF INJURED
DEPT.
PERSONAL
OCCUPATION
DATE OF
TIME
ACIDENT
HOW ACCIDENT HAPPENED (EMPLOYEES STATEMENT)
A.M.
P.M.
DATE REPORTED
TIME
A.M.
P.M.
INJURY
DIABILITY
BEGAN
ESTIMATED
TIME LOST
SEE REVERSE SIDE FOR
ACTUAL
TIME LOST
CODE
RETURNED
TO W ORK
TO COMPLETE THIS SECTION
A PART OF BODY INJURED
B NATURE OF INJURY
ANALYSIS
C TYPE ACCIDENT
D SOURCE or AGENT
E UNSAFE ACT
F HAZARDOUS CONDITION
IMPROVE
REPLACE
CORRECTIVE
REPAIR
TRAIN
WHAT? HOW?
WHAT? WITH WHAT?
WHAT?
WHOM? HOW?
MEASURES
ENFORCE
GUARD
WHAT RULE?
WHAT? HOW?
PROPERTY, MATERIAL OR EQUIPMENT DAMAGED
NATURE OF DAMAGE
PROPERTY
DAMAGE
PERSON RESPONSIBLE
ESIMATED COST OF REPAIRS
AND/OR REPLACEMENT
INVESTIGATED BY
ACTUAL COST OF REPAIRES
AND/OR REPLACEMENT
$
DATE
REVIEW ED BY
Safety is an important part of our business . . .
Make it part of yours!
DATE
A. INJURED PART OF BODY
001
002
003
004
005
06
007
008
Head
Face
Eye
Ears
Nose
Mouth
Neck
Shoulder
009
010
011
012
013
014
015
016
Arm
Elbow
Wrist
Hand
Finger
Back
Chest
Lungs
017
018
019
020
021
022
023
024
B. NATURE OF INJURY
Ribs
Groin
Hip
Leg
Knee
Ankle
Foot
Toes
101
102
103
104
105
106
107
Amputation
Asphyxia
Burn or Scale (Heat)
Concussion
Contusion, Crushing, Bruise
Cut, Laceration, Puncture
Dermatitis
108
109
110
111
112
113
114
Dislocation
Electric Shock
Fracture
Foreign Body
Heat Stroke
Hernia
Infection
115
116
117
118
119
120
Pneumoconiosis
Radiation Effects
Scratches
Sprains, Strains
Multiple Injuries
NOC
C. ACCIDENT TYPE
201
202
203
204
Struck against stationary object
Struck against moving object
Struck by falling object
Struck by flying object
205
206
207
208
209
Fall from elevation
Fall on same level
Caught in, under or between
Over-exertion
Contact with electrical current
210
211
212
213
Contact with noxious substances
Inhalation, absorption injection
Rubber or abraded
Vehicle Accident
NOC
325
326
327
328
329
330
331
332
333
334
335
Pressure vessels
Pumps and prime movers
Radiation substance and equipment
Soaps, detergents, cleaning compounds
Silica
Scrap, W aste material
Steam
Vehicles
Wood items
Working Surface
NOC
D. SOURCE OR AGENT OF INJURY
301
302
303
304
305
306
307
308
309
310
311
312
Air Pressure
Animals, insects
Boxes, barrels, bags, containers
Chemical solid, liquid, gas
Clothing, apparel, shoes
Conveyors
Electrical apparatus
Flame, fire, smoke
Furniture, Fixture
Glass
Hand tools not powered
Hand tools powered
313
314
315
316
317
318
319
320
321
322
323
324
Heating equipment
Hoisting apparatus
Infections and parasitic agents
Ladders
Machines
Mechanical power transmission apparatus
Metal items
Mineral items
Noise
Paper and pulp
Plants, trees, vegetation
Plastic items
E. UNSAFE ACTS
401
402
403
404
405
406
407
408
Cleaning, oiling, adjusting or repairing of moving
electrically energized or pressurized equipment
Failure to use personal protective equipment
Failure to wear safe personal attire
Failure to secure or warn
Horseplay
Improper use of equipment
Improper use of hands or body parts
Inattention to footing or surroundings
409
410
411
412
413
414
415
416
417
Making safety devices inoperative
Operating or working at unsafe speed
Taking unsafe position or posture
Driving errors
Unsafe placing, mixing or combining
Using unsafe equipment
Operating without authority or instructions
Violation of specific instructions
NOC
F. HAZARDOUS CONDITIONS
501
502
Defects of agencies (worn, improperly designed)
503
504
505
506
507
508
509
510
Lack of necessary personal protective equipment
Dress or apparel hazards (improper, inadequate)
Excessive noise
Inadequate aisle space
Inadequate clearance
Inadequate traffic control
Inadequate ventilation
Insufficient workspace
Improper illumination
511 Use of inherently hazardous material or equipment
512 Use of inherently hazardous methods or procedures
521
522
Ungrounded
Uninsulated
513
514
515
516
517
518
519
520
523
524
525
526
527
528
529
Unshielded
Unguarded
Inadequately guarded
Defective premises
Natural Hazard
Traffic hazards
NOC
Use of inadequate or improper tools or equipment
Inadequate help for heavy lifting
Improper assignment of personnel
Improperly piled
Improperly placed
Lack of inadequate shoring
Unlabeled or inadequately labeled material
Unsafe physical condition