Accident Investigation Report

Job Site Name*
Supervisor's Name*
First Last
Employee's Name*
First Last
Foreman's Name*
First Last
Date of Incident*
Date Format: MM slash DD slash YYYY
Time of Incident*

: HH

MM
Vehicle Number
Weather Conditions
Type of Accident*
Cause of Accident*
Results of Accident*
Were Steps Taken To Avoid This Accident?*
- Yes
- No
Were There Any Injuries Involved In This Accident?*
- Yes
- No
Was There Any Damage To Equipment Or Property?*
- Yes
- No
Final Analysis
Employee Signature
Date
Date Format: MM slash DD slash YYYY
Foreman Signature
Date
Date Format: MM slash DD slash YYYY