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SAMPLE FORMAT FOR ACCIDENT AND NEARNESS INVESTIGATION BLANK FORM GUIDE TO COMPLETION OF FORM ACCIDENT AND NEARNESS INVESTIGATION FORM Name of Injured Employee / Person : : Personnel Reference Number

How to fill out accident and near-miss investigation

How to fill out accident and near-miss investigation:

1. Gather all relevant information: Start by collecting details about the accident or near-miss incident, such as the date, time, location, and individuals involved. Also, gather any available witness statements, photographs, or videos related to the incident.
2. Identify the root causes: Investigate the factors that contributed to the accident or near-miss. Interview the people involved and analyze any available evidence to determine the underlying causes. This step is crucial for implementing preventive measures.
3. Fill out an incident report form: Use a standardized incident report form to document all the necessary information. This form should include sections to record details about the incident, its causes, and any recommended corrective actions. Make sure to include a section for witness statements and possible contributing factors.
4. Describe the events in chronological order: Provide a clear and concise description of the incident, including what led up to it, the events that occurred during the incident, and the immediate aftermath. Use objective language and avoid making assumptions or speculations.
5. Analyze contributing factors: Identify the factors that played a role in the accident or near-miss. This could include issues such as equipment failure, human error, lack of training, or environmental conditions. Evaluate all the potential causes to determine the most significant factors.
6. Determine corrective actions: Based on the analysis of contributing factors, propose appropriate corrective actions to prevent similar incidents in the future. These actions may involve changes in procedures, additional training, equipment upgrades, or revisions to safety protocols. Ensure that the corrective actions are realistic, actionable, and assigned to responsible parties.

Who needs accident and near-miss investigation:

1. Organizations: Any organization, regardless of its size or industry, should conduct accident and near-miss investigations. This allows them to identify potential hazards, evaluate their safety measures, and make improvements to prevent recurrences.
2. Safety and health professionals: Individuals working in safety and health roles within organizations play a key role in accident and near-miss investigations. They are responsible for leading the investigation process, analyzing incidents, and implementing preventive measures.
3. Employees: Employees who witness or are involved in accidents and near-misses should report these incidents to their supervisors or safety representatives. Their active participation in the investigation process helps in identifying causes and contributing factors accurately.
4. Regulatory agencies: Regulatory agencies overseeing workplace safety often require organizations to conduct accident and near-miss investigations. These agencies rely on the findings to monitor compliance, identify trends, and enforce safety regulations.

In summary, anyone involved in an accident or near-miss incident, from employees to safety professionals and regulatory agencies, can benefit from accident and near-miss investigations. By following a systematic process and involving all stakeholders, organizations can identify the causes of incidents and implement corrective actions to prevent future occurrences.

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What is accident and near-miss investigation?

Accident and near-miss investigation is the process of analyzing incidents that have occurred or almost occurred to identify causes and prevent future occurrences.

Who is required to file accident and near-miss investigation?

Employers are typically required to file accident and near-miss investigations to ensure workplace safety and compliance with regulations.

How to fill out accident and near-miss investigation?

Accident and near-miss investigations are usually filled out by documenting details of the incident, including date, time, location, individuals involved, and contributing factors.

What is the purpose of accident and near-miss investigation?

The purpose of accident and near-miss investigation is to identify causes of incidents, implement corrective actions, and prevent future accidents or near-misses.

What information must be reported on accident and near-miss investigation?

Information to be reported on accident and near-miss investigation typically includes details of the incident, injuries sustained, witnesses, and corrective actions taken.