Accident Investigation Form Name of organisation: Branch/department: …………………………. …………………………….. PARTICULARS OF ACCIDENT Date of accident Time Location Date reported M T W T F S S THE INJURED PERSON Name Address Age Phone number Date of accident Length of employment at plant on job TYPE OF INJURY: Bruising Dislocation Other (specify) Injured part of body    Strain/sprain Scratch/abrasion Internal    Fracture Amputation Foreign body Remarks    Laceration/cut Burn scald Chemical reaction    DAMAGED PROPERTY Property/ material damaged Nature of damage Object/substance inflicting damage THE ACCIDENT Description Describe what happened overleaf for diagram essential for all vehicle accidents) Analysis What were the causes of the accident? HOW BAD COULD IT HAVE BEEN? WHAT IS THE CHANCE OF IT HAPPENING AGAIN? Very serious Serious Minor Minor Occasional Often       Prevention What action has or will be to prevent a recurrence? Tick items already actioned By whom When Use space overleaf if required TREATMENT AND INVESTIGATION OF ACCIDENT Type of treatment given Name of person giving first aid Doctor/Hospital Accident investigated by Date DOL advised YES / NO Date Appendix 10: Document 6: WorkSafe Notification Form
Accident Investigation Form Name of organisation: …………………………. Branch/department: …………………………….. PARTICULARS OF ACCIDENT Date of accident M T W T F S S Time Location Date reported THE INJURED PERSON Name Address Age Phone number Date of accident Length of employment at plant on job TYPE OF INJURY:  Bruising  Dislocation  Other (specify) Injured part of body  Strain/sprain  Scratch/abrasion  Internal  Fracture  Amputation  Foreign body Remarks  Laceration/cut  Burn scald  Chemical reaction DAMAGED PROPERTY Property/ material damaged Nature of damage Object/substance inflicting damage THE ACCIDENT Description Describe what happened overleaf for diagram essential for all vehicle accidents) Analysis What were the causes of the accident? HOW BAD COULD IT HAVE BEEN? WHAT IS THE CHANCE OF IT HAPPENING AGAIN?  Very serious  Serious  Minor  Minor  Occasional  Often Prevention What action has or will be to prevent a recurrence? Tick items already actioned By whom When Use space overleaf if required TREATMENT AND INVESTIGATION OF ACCIDENT Type of treatment given Name of person giving first aid Doctor/Hospital Accident investigated by Date DOL advised YES / NO Date Appendix 10: Document 6: WorkSafe Notification Form