Accident Investigation/Root Cause Analysis Form

General Information

OBTAIN AND REVIEW physical evidence, employee/witness information, and paper evidence pertinent to the investigation.

Physical— photographs, drawings, equipment manuals.
Employee/Witnesses— statements, interviews, WSI First Report of Injuryform
Paper— policies, programs, training records, maintenance records, incident reports

Basic Details

Employee First Name^*

Employee Last Name^*

WSI Claim Number

County^*

Accident Location^*

Was Employee Working Alone?^*

Yes

No

Injury Date^*

Body Part

Nature of Injury

Witness Details

First Name⁺ Last Name⁺ Email Add Witness

How much experience did the employee have in performing this task?

What task was being performed, how did the accident happen, and explain the nature of the injury?

Describe any tools, machinery, equipment, or PPE that was being used at the time of the accident?

Root Cause Analysis

What is the proximal root cause of this injury?^* (A proximate cause is an event which is closest to, or immediately responsible for causing, some observed result. Examples may include: inmate spit in my face; vehicle struck object, sharp metal cut hand, etc.)

Why?^*

Why?

What is the root cause/s of this incident?^*

Steps For Corrective Action and Projected Completion Date

Engineering Controls-Eliminate/reduce hazards through equipment redesign, enclosure, replacement, substitution, etc.
Administrative Controls-Eliminate/reduce frequency and duration ofexposure through changes ofwork procedures and practices, scheduling, job rotation, breaks, training, or additional training etc.
Personal Protective Equipment-for personal use that present a barrier between worker and hazard.

Please enter corrective action details when applicable else below fields are optional. If applicable all fields marked * are required on each row

Choose Controls⁺

Estimated Completion Date⁺

Notes⁺

Add New

Attachments

OBTAIN AND REVIEW physical evidence, employee/witness information, and paper evidence pertinent to the investigation.

Physical—photographs, drawings, equipment manuals
Employee/Witnesses—statements, interviews, WSI First Report of Injury form
Paper—policies, programs, training records, maintenance records, incident reports

Files

Signature

Risk Manager

First Name^*

Last Name^*

Check Box to Sign^*