ABSTRACT
Date of Accident ______________________ Date Reported _____________________
Employee(s) Names(s) __________________________________________________________
Time of Accident ______________________________________________________________
Location of Accident ___________________________________________________________
Department Shift Supervisor ____________________________________________________
Machines/Tools/Processes/Operations Involved _____________________________________
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Brief Description of Injuries _____________________________________________________
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Property Damage_______________________________________________________________
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Witnesses _____________________________________________________________________
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Check each item that contributed to the accident:
Summary of Investigation: _______________________________________________________
______________________________________________________________________________
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_______________________________________________ _________________________ Signature/Title Date
Corrective Actions ______________________________________________________________
______________________________________________________________________________
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_______________________________________________ _________________________ Signature/Title Date
Comments ____________________________________________________________________
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Initials ______________________________ Date Reviewed _____________________
Sent to _______________________________________________________________________
