Pub. 3 2015 Issue 4

22 San Diego Dealer ACCIDENT INVESTIGATION REPORT Employee Name: ______________________________________________ Age: __________________ Hire Date: Employee Position: ______________________________________ Accident Date: ___________Time: __________AM/PM Date Reported to Company/Supervisor: Time Reported: Location of Accident ( be specific ): Equipment Operated During Accident ( if any ): Part of Body Affected/Injured: Task Being Performed When Accident Occurred: Description of Accident: Check If Any of the Following was Applicable: ☐ Doing Normal Work Duty ☐ Improper Tool ☐ Improper Procedures ☐ In a Hurry Was Employee Injured: Yes _______ No _______ Describe Injury ( and loss/restricted body movement at the time of accident, if any : Loss/Restricted Body Movement at Time of Investigation ( if any ): Date and Time Employee Sought Medical Attention: Clinic/Hospital Injured Taken To: Detail of Treatment ( attach Dr. Report if available ): Investigation of Location and/or Equipment that Caused Accident: Corrective Measures (note if management action required): Check if Applicable: ☐ Issue Personal Protective Equipment ☐ Repair/Replace Equipment ☐Third Party Involved in Accident ☐ Issued Written or Verbal Counseling ( circle one ) Witness 1 Name: _______________________________ Statement Date: Time: Statement: Witness 2 Name: _______________________________ Statement Date: Time: Statement: Attach Employee Statement ( if any ) Report Completed By: Signature Name and Title Date