Completing The Supervisor’s Accident Investigation Form

When completing the Supervisor’s Accident Investigation form, keep the following in mind:

1. How did the accident occur?  Where and how did the employee get hurt?  Get all the facts.
Describe the accident in detail; don’t leave anything out. You have to ask a lot of questions – even some you might think are unnecessary. A good tip is to ask 5 or 6 more questions than you think necessary. Be sure you have all the facts before continuing.

2. Was the accident the result of some physical hazard?  What went wrong?  And why?
Was it an unsafe condition (physical hazard) such as improperly guarded, defective, misused, missing equipment; a housekeeping issue, improper illumination, improper ventilation; unsafe design; unsafe dress; unsafe hazardous materials arrangement?

Are there conditions likely to cause any of the following types of accidents: Caught in or between – pinch points; fall to same or lower level; an abrasion, laceration, or puncture wound; a sprain or strain; struck by or against – falling, moving, sliding, flying objects; a contact – electrical conductor, a caustic or acid, radioactive particle, hot objects, fire, dust, vapor gases.

If it was one of these – why?

3. Was the accident the result of unsafe acts?  Would a cautious or well-trained person have done the same thing under the same circumstances?  If no, why?
Was it an unsafe act, such as: operating without authority; operating or working at unsafe speed; making safety devices inoperative; using unsafe equipment or not using equipment safely; unsafe loading – mixing, piling, etc.; unsafe position or posture – working on moving machinery; horseplay, distracting, etc.; failure to warn; other?

If it was one of these – why was it?  Did someone else contribute to the accident?

4. What do you recommend we do to keep this accident from happening again?
If one employee did it, what will keep the others from doing it? If it happened to one, will it happen to others?

Supervisor’s Accident Investigation Form

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