Accident Investigation Questions – Southam and Associates

Supervisor Name *

First

Last

Employee's Name *

First

Last

Company

Date of Injury / Incident *

Summary of Injury / Incident: *

If incident involves an injury, has employee filed a First Report of Injury with HR? *

In incident involves and injury, did you accompany the injured employee to Work Med? *

Was the employee wearing the appropriate safety gear? i.e. Safety Glasses *

If you answered no, why wasn't the employee wearing the required / appropriate safety gear?

How could this accident have been prevented? *

What safety rules are in place to prevent this type of accident? *

Were there environmental or work conditions that contributed to the accident and if yes, how can we correct them? *

Please summarize a corrective action plan here to prevent this type of accident in the future for your department/crew? *