JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Accident Investigation Form
Use this form to help investigation workplace accidents or incidents, after an incident report has been placed.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Investigator Name:
*
Your answer
Date of Accident Investigation Completion
*
MM
/
DD
/
YYYY
Location:
*
Choose
Alberta
Division
Eugene
Lake Oswego
Mississippi
Multnomah Village
NW 23rd
Orenco Station
Pearl District
Progress Ridge
South Waterfront
University of Oregon
Name of Accident Victim
*
Your answer
Victim's Job Title
*
Associate
Key Employee
Shift Supervisor
Other:
How long has accident victim been with this company? How long on this job?
*
Your answer
Name all witnesses to the incident:
*
Your answer
Date of Incident:
*
MM
/
DD
/
YYYY
Around what time did the incident occur:
*
Time
:
AM
PM
What happened? (Describe sequence of events and extent of injury)
*
Your answer
Has a similar accident ever occurred?
*
Yes
No
If Yes, when?
Required
What caused the accident? (List all causes and contributing factors, which might include lack of supervision, inadequate training, poor equipment maintenance, and inadequate policy)
*
Your answer
List each corrective action to be taken. Who will do it and when will it be done?
*
Your answer
Please send any photographs, sketches of the scene, or other relevant information to
support@littlebigburger.com
Submit
Page 1 of 1
Clear form
Never submit passwords through Google Forms.
This form was created inside of Spark Team Hospitality.
Report Abuse
Forms
