Accident Investigation Report

Date of investigation

Investigator

Date of injury

Injured worker

Project location

Project Supervisor

M.O.L. notified?

No

Yes

Joint H & S Committee in place?

No Yes

Injured workers
address:
Nature of injury reported (injured body
part):
Factors that led up to accident:

Project Safety Representative:

Comments:

Names and addresses of witnesses and their comments (please use back for additional comments):

Recommendations for corrective measures:

Corrective measures taken?

Investigator Signature

N/A

Yes

To follow up on

President

(Date)