Microsoft Word - Accident Exposure Investigation

THERMA

Job Site:		Date:
Investigation Team:		Job Number:
Employee Name:		Employee ID #:
Sex:		Job Description:
Department:		Time of Work (Start):
Project Manager:		Foreman:
General Foreman:		Journeymen/Leadsman:
Accident Date:		Time of Accident:
Date Reported to Supervisor:		Time Reported:
Date of Investigation:		Time of Investigation:
Nature of Incident:
Type of Injury:
Referred to Medical Facility/Doctor: Yes No
Did Employee Return to Work? Yes No Date/Time:
Injured Employee Interview/Statement:


Witnesses Interviews/Statements (Explain):

Photograph(s) of Site:(attach)		Diagram(s) of Site:(attach)
Equipment Records Reviewed: Yes No Attached
Accident/Exposure Incident Description:



Root Cause:
Corrective Action Plan and Responsibility:


PPE's Used/Needed:

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Additional Information: