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Accident Analysis Worksheet
Identifying the root cause of a workplace accident or injury is critical to preventing a similar incident from happening again. After completing the initial employee accident report and statements, then use this analysis to identify and document the root cause of an incident. Attach other pages as needed to document the entire event.

Free Sample Template
Format: Word PDF
# of Pages: 1
Printable: Yes


Other forms related to workplace accidents
About Employee Accidents
Employee Accident Report
Sample Employee Letter
Accident Report Log


Accident Analysis Worksheet TemplateForm 1009
Format: Word PDF
Category: Employee, Accident
Type: Form
Accident Analysis Worksheet




Company Name: _______________________________________________________________________________

Employee: _______________________________ Department: __________________________________________

Supervisor: ______________________________ Incident Location: ____________________________________

Witnesses: ____________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Date and Time of Incident: _______________________________________________________________________

Date and Time Reported: ___________________________________________________________________

Please provide a detailed account of the incident: _____________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________


Identify the system problems that contributed to the incident:___________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

How should we best take corrective action so the above mentioned incident does not occur again: _____________

_____________________________________________________________________________________________

_____________________________________________________________________________________________



Supervisor Signature: _______________________________________________________ Date: ___/___/____