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FORM 421-2 Adopted Last Revised Review Date June 10, 2010 October 2012 October 2013 Annual Review SUPERVISOR'S ACCIDENT/VIOLENT INCIDENT INVESTIGATION REPORT CHECK ONE: ? ACCIDENT ? VIOLENT INCIDENT.

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How to fill out the Accident Investigation Report online

Completing the Accident Investigation Report online is a vital step in ensuring workplace safety and accountability. This guide will provide you with clear, step-by-step instructions on how to accurately fill out each section of the form.

Follow the steps to accurately complete the form.

  1. Click ‘Get Form’ button to obtain the form and open it in the editor.
  2. Indicate whether the report pertains to an accident or a violent incident by checking the appropriate box. Fill in the school or location and the exact site of the incident.
  3. Enter the date and time of the incident as well as the date and time the report was filed.
  4. Provide the name of the injured person and the name of the individual reporting the incident.
  5. Fill in the occupation of the injured person and classify the injury. Select the relevant options from the provided injury classifications.
  6. If health care or first aid was administered, specify the date, time, and the individual who provided the care.
  7. Describe the incident thoroughly, including details on how it occurred and names of any witnesses present.
  8. Indicate whether any sketches or pictures are attached by checking 'Yes' or 'No'.
  9. Analyze the causes of the incident by listing any actions, inactions, circumstances, or conditions that contributed to it.
  10. Document any preventative actions taken by the supervisor to mitigate future incidents.
  11. State whether employee conduct played a role in the incident by answering 'Yes' or 'No'.
  12. Sign the report and include the date to validate the document.
  13. Once completed, ensure that the report is sent to Human Resources Support Services as soon as possible, preferably within 24 hours. You can choose to save changes, download, print, or share the form as necessary.

Take the first step towards improving workplace safety by completing the Accident Investigation Report online today.

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Incident Description. Date / Time / Location. Details of injuries / Damage to equipment / Environmental impact / Impact on production or operations. Risk rating (actual and potential consequence) Photographs. Timeline / Sequence of events.

Information to Identify the Case: Begin the report with case specific information that identifies the case the report is related to. ... Referral Source: ... Allegation Details: ... Information About the Subject: ... Investigation Scope/ Purpose: ... Case Notes: ... Interview Summaries: ... Interview Reports:

Scene management and scene assessment (secure the scene, make sure it is safe for investigators to do their job). Witness management (provide support, limit interaction with other witnesses, interview). Investigate the incident, collect data. Analyze the data, identify the root causes.

Preserve and Document the Incident Scene. An incident investigator's first priority should be to ensure that the incident site is safe and secure. Collecting Information. a Interviewing witnesses. Determine Root Causes. Implement Corrective Actions.

Date, time and specific location of incident. Names, job titles and department of employees involved and immediate supervisors. Names and accounts of witnesses. Events leading up to incident. Specifically what the employee was doing at the moment of the accident.

Start With What You Know. The investigator should record the information about the subject (respondent or accused person) and the details of the complaint. ... Make Sense of What You Have. Evidence analysis can substantiate claims from either party. ... Formulate a Conclusion.

Type of incident (injury, near miss, property damage, or theft) Address. Date of incident. Time of incident. Name of affected individual. A narrative description of the incident, including the sequence of events and results of the incident.

Step 1: Ensure Confidentiality. ... Step 2: Provide Interim Protection. ... Step 3: Select the investigator. ... Step 4: Create a Plan for the Investigation. ... Step 5: Develop Interview Questions. ... Step 6: Conduct Interviews.

The investigative process is a progression of activities or steps moving from evidence gathering tasks, to information analysis, to theory development and validation, to forming reasonable ground to believe, and finally to the arrest and charge of a suspect.

Step 1: Gather information. Get a brief overview of the situation from witnesses and employees directly involved in the incident. ... Step 2: Search for and establish facts. ... Step 3: Establish essential contributing factors. ... Step 4: Find root causes. ... Step 6: Implement corrective actions.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Privacy Notice
Legal Hub
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate WorkFlow
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232