Sample workplace accident investigation form

Accident information

Date of accident: __________________________________ Date of report: _______________________________________

Where did the accident occur? ___________________________________________________________________________

Time of accident: __________________

a.m.
p.m.
On site
Off site

Name(s) of injured: ____________________________________________________________________________________

Are these company employee(s)?

Contractors?

Names of non-company individuals (if applicable): ____________________________________________________________

____________________________________________________________________________________________________

Occupation of employee(s): ______________________________________________________________________________

Witnesses to accident: __________________________________________________________________________________

Description of any property damage: _______________________________________________________________________

____________________________________________________________________________________________________

Description of events: __________________________________________________________________________________

____________________________________________________________________________________________________

Contributing factors

Act(s) (describe): ______________________________________________________________________________________

____________________________________________________________________________________________________

Conditions (describe): __________________________________________________________________________________

____________________________________________________________________________________________________

Root cause(s) of accident: _______________________________________________________________________________

____________________________________________________________________________________________________

Corrective actions to take

(Describe what actions need to be taken to prevent a reoccurrence)

Corrective action	Person responsible	Date completed

Report developed by:______________________________________ Dept.: ______________________________________

Report reviewed by:_______________________________________ Date:_______________________________________

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This material is provided for informational purposes only and does not provide any coverage or guarantee loss prevention. The examples in this material are provided as hypothetical and for illustration purposes only. The Hanover Insurance Company and its affiliates and subsidiaries (“The Hanover”) specifically disclaim any warranty or representation that acceptance of any recommendations contained herein will make any premises, or operation safe or in compliance with any law or regulation. By providing this information to you, The Hanover does not assume (and specifically disclaims) any duty, undertaking or responsibility to you. The decision to accept or implement any recommendation(s) or advice contained in this material must be made by you.

171-0830 (1/14) LC 12‐169

Sample workplace accident investigation form

Accident information

Date of accident: __________________________________ Date of report: _______________________________________

Where did the accident occur? ___________________________________________________________________________

Time of accident: __________________

a.m.
p.m.
On site
Off site