ACCIDENT INFORMATION

Date of Accident Time Day of Week Shift Department

S MTWTFS 1 2 3

INJURED PERSON / S-
Name: Address:
Age: Phone:
Job Title: Supervisor’s Name:
Length of Employment at Company: Length of employment at Job:
Employee Classification: Full Time Part Time Contract Temporary
Nature of Injury Bruising Dislocation Other (Specify) Injured Part of
Body:
Strain/sprain Scratch/Abrasion Internal
Fracture Amputation Foreign Body Remarks
Laceration/Cut Burn/Scald Chemical
Reaction
Treatment Name and Address of Treating Physician or Facility
First Aid
Emergency Room
Dr’s Office
Hospitalization
Contact Persons
1. Next of keen 3. Supervisor 5. Fleet Manager 011 631 890
2. Police 999 4. Asset Protection 0912400260

DAMAGED VEHICLES / PROPERTY

Vehicle Property, Equipment, Material Damaged: Describe Damage:

DESCRIPTION
Describe what happened (attach photographs or diagrams if necessary)

ROOT CAUSE ANALYSIS (Check All that Apply)

Unsafe Acts Unsafe Conditions Management Deficiencies
Improper lane use Light condition Lack of written SOPs, policies
 Rule violation Weather condition Safety rules not enforced
Seat belt not used Traffic condition Hazards not identified
Driving without authority Driver condition Improper maintenance
Failure to warn / indicate Vehicle condition Insufficient training
Unsafe speed Excessive noise Inadequate inspection
Failure to give way Unsafe design/construction
Illegal maneuver Unrealistic scheduling
Improper loading
Lack of caution
Driving without due care Road condition
Horse play Wide tar
Drug or alcohol use Strip tar
Unnecessary haste Gravel road
Unsafe acts of others

Other: Other: Other:

ACCIDENT DIAGRAM JUST BEFORE IMPACT

Detailed Report and Analysis

Using the root cause analysis list, explain the cause(s) of the incident in as much detail as possible:
INVESTIGATING TEAM REPORT:

How bad could the accident have been? What is the chance of the accident happening again?
Very Serious Serious Minor Frequent Occasional Rare

PREVENTIVE ACTIONS
Describe actions that will be taken to prevent recurrence Deadline By Whom Complete

INVESTIGATION TEAM
Signature Name Position