Instructions: Investigator should complete all sections of the accident report. It will help to systematically reveal the factors that contributed to the accident, what the actual root causes were and what preventative actions should be implemented to keep similar events from happening in the future.
SECTION 1 – Accident Information
Type of Accident:	Near Miss	Occupational Injury or Illness
Motor Vehicle Accident	Special-Purpose Vehicle Accident
Other:
Date of Occurrence:	Time of Occurrence:	a.m.	p.m.
Location: W
Who was Accident First Reported To:
Date Reported:	Time Reported:	a.m.	p.m.
Describe any Property Damage:
Name of Employee Involved:
Severity of Injury:	No Injury	Minor Injury	Major Injury	Fatality
Work Unit:
Work Phone:
Supervisor:
Employment:	Full-Time Employee	Part-Time Employee	Temporary Employee	Volunteer
Time in Job:
Describe Injury:
Name of Employee Involved:
Severity of Injury:	No Injury	Minor Injury	Major Injury	Fatality
Work Unit:
Work Phone:
Supervisor:
Employment:	Full-Time Employee	Part-Time Employee	Temporary Employee	Volunteer
Time in Job:
Describe Injury:

Name of Employee Involved:
Severity of Injury:	No Injury	Minor Injury	Major Injury	Fatality
Work Unit:
Work Phone:
Supervisor:
Employment:	Full-Time Employee	Part-Time Employee	Temporary Employee	Volunteer
Time in Job:
Describe Injury:
SECTION 2 – Written Accounts of Accident
Investigator will interview employees involved in the accident and witnesses to the accident, or have them provide a written account of what happened from their perspective. This will be done as soon after the accident as possible. Their accounts should accompany the final accident report and include the following information:
1.	Description of injuries
2.	Description of property damage
3.	Any unsafe conditions, or unsafe acts, he or she feels may have contributed to the accident
4.	Describe what happened… provide as much detail as possible on events leading up to the accident, how the accident itself happened and what took place after the accident.
SECTION 3 – Investigation
Investigator will gather all pertinent information to help in understanding possible causes of the accident. This should include physical evidence from the scene; background information on the involved parties (training, experience, etc.); organizational climate and norms at time of accident; applicable policies and procedures; etc.
SECTION 4 – Accident Analysis
As interviews are conducted and evidence is collected or reported during the investigation, events that influence the accident will be entered into the Form 8.23 Accident Analysis Matrix. The matrix will then be used to piece together a final sequence of events, and to determine causes and severity factors of the accident. The matrix should accompany the final accident report.
SECTION 5 – Report of Findings
After a thorough review of all evidence, the investigator will write a final report. The written report, along with information from sections 2 - 5 above, will be submitted to the Agency Safety Officer and the involved employee’s supervisor. The report will:
Provide a final sequence of events as determined by the investigator to have taken place (will include events leading up to the accident, during the actual moments of the accident, and after the accident).
Identify the direct causes of the accident and the injury/ies (the actual thing that caused injury or damage…struck by a tree limb, fell off ladder and hit pavement, etc.).
Identify contributing causes of the accident (unsafe conditions and/or behaviors).
Identify severity factors (conditions that contributed to the severity of the accident or injury but did not cause it).
Identify root causes of the accident (organizational deficiencies such as training, procedures, complacency, etc.).
Identify preventative actions (short-term measures that can reduce or eliminate unsafe conditions/behaviors; long-term measures that address root causes).
SECTION 5 – Signature
Investigator Name (Print)	Investigator Signature	Date