Forms Stitch It

Accident / Incident Investigation & Prevention Form

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(To be completed by Human Resources or the designated Health and Safety Representative)

Date *

Store Number *

Type of report *

Who Reported the Incident / Accident *

First

Last

Person Involved in Incident/Accident *

First

Last

Customer Phone Number *

Witness of Incident

First

Last

Could this incident/accident been avoided? *

Yes
No

If Yes, explain HOW this accident could be avoided in the future below:

CAUSES: What acts or conditions could cause the event? (check all that apply)

Contributing Actions or Unsafe Acts:

Failure to warn
Failure to secure
Making safety devices inoperable (removing guards)
Using defective equipment
Failure to use required personal protective equipment (e.g., closed-toe shoes)
Improper loading or placement
Improper lifting or body position
Servicing equipment while in operation
Horseplay
Other

Substandard Conditions:

Inadequate guards or barriers
Inadequate or improper protective equipment
Defective tools, equipment, or materials
Congestion or restricted movement
Inadequate warning system or signage
Fire or explosion hazard
Poor housekeeping or disorder
Hazardous environmental conditions (gases, smoke, dust, fumes)
Slippery or uneven flooring
Inadequate lighting or ventilation
Other

Basic Causes – Personal Factors:

Inadequate capability (physical or mental)
Lack of knowledge or training
Lack of skills or experience
Stress, fatigue, or distraction
Improper motivation or attitude toward safety
Other

Basic Causes – Job/System Factors:

Inadequate leadership or supervision
Inadequate engineering or workspace design
Inadequate maintenance
Inadequate tools or equipment
Inadequate work standards or procedures
Wear and tear or equipment failure
Abuse or misuse of equipment or materials
Other

Actions and Follow Up to Prevent Recurrence (Check applicable factors):

Correct congested area.
Repair or replace tool or equipment.
Install guard or safety device.
Improve personal protective equipment.
Update training.
Reinstruct person involved and provide support or coaching.

What actions are planned or has been taken to prevent a recurrence of the accident/incident, based on the key contributing factors. *

Please include what, why and how recommendations are made, the party responsible and the expected date.

Signature of HR Rep or Health and Safety Rep *

Clear Signature

Name

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