Vesta Property Services
Accident Investigation Report
Instructions
An accident investigation is not designed to find fault or place blame, but it is an analysis of the accident to determine causes that can be controlled or eliminated.
ClaimType: Record only: First aid type injury resulted in minor injury/treated on premises or employee refused treatment;
Medical—injury treated off premises by physician;
Lost time—injured missed more than one day of work; No Injury—no injury, near-miss type of incident.
(Items 1-10)Identification: This section is self-explanatory.
(Item 11)Nature of Injury, Type and Body Part: Describe the injury, e.g., strain, sprain, cut, burn, fracture. Part of the body directly affected, e.g., foot, arm, hand, head.
(Item 12)Describe the accident: Describe the accident, including exactly what happened, and where and how it happened. Describe the equipment or materials involved.
(Item 13)Cause of the accident: Describe all conditions or acts which contributed to the accident, e.g.—
a.unsafe conditions (spills, grease on the floor, poor housekeeping or other physical conditions).
b.unsafe acts (unsafe work practices such as failure to warn, failure to use required personal protective equipment).
(Items 14-19)These sectionsare self-explanatory.
(Item 20) Witness(es): List name(s), address(es), and phone number(s).
(Item 21) Does Vesta Property Services contribute to employees health insurance or other benefits:
What is the contribution amount that Vesta Property Services pays for the employees health benefits, 401K, car allowance, housing etc.
(Item 22) Interim corrective action: Measures taken by supervisor to prevent recurrence of incident, e.g., barricading accident area, posting warning signs, shutting down operations.
(Item 23):This section is self-explanatory.
(Item 24):This section is self-explanatory.
(Item 25) Follow-up: Once the investigation is complete, the safety coordinator shall review and follow up the investigation to ensure that corrective actions recommended by the safety committee and approved by the employer are taken and that control measures have been implemented.
Claim Type: Record-Only _____ Medical-Only_____ Lost Time ______
1. Name of injured:______2. S.S. No.:______
3. Sex: M F 4.Birth Date: ______Age: ______5. Date of accident: ______
6. Time of accident: ______a.m. ______p.m. Day of accident: ______
7. Employee’s job title: ______
8. Length of experience on job: ______years ______months 9. Date of Hire: ______
10. Address of location where the accident occurred: ______
11. Nature of injury, injury type, and part of the body affected:______
12. Describe the accident and how it occurred: ______
______
13. Cause of the accident: ______
14. Did employee seek medical treatment beyond first-aid? yes no
If yes, what was the name address and phone where was employee treated? ______
How was employee transported to facility? ______
15. Date employee notified Vesta Property Services of injury and to whom?: ______
16. Date employee returned to work: ______Is employee making pre-injury wage?: yes no
17. Days missed since accident:______18. Is restricted/modified duty available?: yes no
19. Employee wages: ______hr wk bi-wk month
20. Witnesses (Name and contact info):______
21. Does Avalon Park contribute to employee’s health insurance or other benefits? Yes No
If yes, what benefits how much and how often? ______
22. Interim corrective actions taken to prevent recurrence: ______
______
23. Permanent corrective action recommended to prevent recurrence:______
______
24. Date of report: ______, ______20 ____ Prepared by:______
(Signature): ______Date:
25. Status and follow-up action taken by safety committee member: ______
______
______
Approved: Safety Coordinator (Signature) ______Date______
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