# THERMA

# ACCIDENT/EXPOSURE

# INVESTIGATION REPORT

| 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 Medical Facility/Doctor: |  |
| Did Employee Return to Work? Yes No Date/Time: |  |
| Injured Employee Interview/Statement: |  |
|  |  |
| Witnesses Interviews/Statements (Explain): |  |
|  |  |
| Photograph(s) of Site:(attach) Yes No Diagram(s) of Site:(attach) Yes No |  |
| Equipment Records Reviewed: Yes No Attached |  |
| Accident/Exposure Incident Description: |  |
|  |  |
| Root Cause: |  |
| Corrective Action Plan and Responsibility: |  |
| PPE's Used/Needed: |  |

***Please use back side for any additional information.***

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**Additional Information:**

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