Accident Investigation Form Miami – Fill Out and Use This PDF

City of Miami Parks and Recreation Department Safety Handbook

Appendix/Forms

Accident Investigation Form

ACCIDENT INVESTIGATION FORM

Accident Category:

EXPOSURE TO HAZARDOUS SUBSTANCES

PROPERTY DAMAGE

INJURY

ILLNESS

NEAR-MISS

NON-INJURY

OTHER

Name of employee injured, ill or exposed (if applicable):

Classification:

What is the apparent nature of the employee’s injury/illness?

THE ACCIDENT SCENE: Describe the accident scene. Where did the accident happen?

(Example: In the 2nd floor stairwell at 4:20 pm of the Miami Riverside Center Bldg.)

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City of Miami Parks and Recreation Department Safety Handbook

Appendix/Forms

Accident Investigation Form

THE ACCIDENT OR EVENT: Describe what happened. (Example: the maintenance worker removed the cap from the gasoline tank. The gas spilled onto the ground causing the worker to slip and fall. The worker twisted his ankle and broke his arm when he fell).

IDENTIFY WHAT WAS BEING USED: What objects/tools/substances were involved?

(Example: The ladder was not supported; the table saw was in the “on” position; possible lack of oxygen in the confined space; soap and water; cleaning solvent).

DESCRIBE THE WORK ENVIRONMENT? Describe the weather, temperature, light, noise, machinery, aisles, and other features existing at the time of the accident.

WHAT VEHICLE/EQUIPMENT WAS BEING USED (IF ANY)? List the type, brand, name, size, features, condition, age, parts involved, etc. (Include C-No. and Item No. where applicable).

WHAT WAS THE SPECIFIC TASK/WORK ACTIVITY? (Example: Repairing a computer, walking up the stairs, flagging traffic, sitting at a drafting table, walking).

OTHER SPECIFIC ACTIVITY? (Example: posture, movement, using power impact wrench, squatting under conveyor belt, pushing mail cart, lifting copy machine cover, etc.)

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City of Miami Parks and Recreation Department Safety Handbook

Appendix/Forms

Accident Investigation Form

THE WORK CREW: How many in work crew? Working alone or with others?

TIME FACTORS AND THE TIME OF DAY: Describe the time factors related to the shift.

(Example: First half of shift, overtime, rotating, straight eight, rest period, lunch break, entering/leaving the work area).

PERSONAL PROTECTIVE EQUIPMENT/PREVENTIVE MEASURES: Describe protective

equipment being used. (Example: hard hat, glasses, gloves, clothing—did apparel affect the accident?) Were all safety guards in place?

WORK / SAFETY STANDARDS: Did standards exist for the job? Were they written, verbal, followed and understood? Did the employee willfully violate any safety rules?

SCHEDULING OF WORK: Could the work/task have been scheduled at a different time or date?

SUPERVISION: What was the nature of the supervision? Was the supervisor present? Lead worker present?

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City of Miami Parks and Recreation Department Safety Handbook

Appendix/Forms

Accident Investigation Form

TRAINING / INSTRUCTION: Had the employee specifically trained in the activity?

OTHER COMMENTS:

INVESTIGATED BY:

DATE:

Supervisor / Investigator

RECOMMENDATIONS:

The following corrective actions are recommended:

1.

2.

3.

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City of Miami Parks and Recreation Department Safety Handbook

Appendix/Forms

Accident Investigation Form

RECOMMENDATIONS APPROVED:

By:Date:

Comments:

COPY SENT TO:

Date:

USE THIS SPACE FOR NOTES, SKETCHES AND/OR DRAWINGS:

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