Aiwp accident::Incident & investigation form checklist
Accident::Incident
What does this form include?
This form contains 13 sections:
Select date Date
Part A. Accident/Incident portion.
- Name Branch that employee was working for:
Marital Status:
Number of Dependents
Number of Dependents under 18
Where was the Medical treatment first provided?
Add signature
Part B. Investigation portion.
- Employee Name (First, MI, Last)
- Contract Relationship (Company Name)
- Date of Hire:
Severuty:
Action:
- What was the immediate action taken to correct the issue (how was this done):
- Who was the responsible party for correcting the issue:
Statement of Employee involved in the accident/incident
- Please provide date of incident,time, phone number and description of the incident according to the employee in his words:
Statement of the Witness (1)
- Name of witness, Company that he / she works for, Phone Number, Date and Time of the accident/incident according to the witness.
- Statement in his words:
Statement of the Witness (2)
- Name of witness, Company that he / she works for, Phone Number, Date and Time of the accident/incident according to the witness.
- Statement in his words:
Use this template