Workplace Accident Investigation Checklist

General Information

Date of Incident Time of Incident Location Name of Injured Employee(s) Job Title Department Person Completing Report

Incident Description

Describe what happened Describe the injury/damage

Immediate Actions Taken

• Provided first aid/medical attention
• Secured area/equipment
• Notified supervisor/management
• Investigated scene

Witnesses

Names and Contact Information

Contributing Factors

• Unsafe acts
• Unsafe conditions
• Lack of training
• Equipment failure
• Procedures not followed
• Other

Root Cause(s)

Identify root causes

Corrective Actions

• Repair or replace equipment
• Update procedures
• Provide additional training
• Implement new controls
• Other

Describe actions taken or to be taken

Review & Follow-up

Person responsible for follow-up Completion date Additional comments