1. Review Case Study #1 - Sam's Accident.doc
2. Complete the Accident Investigation Report. ACCIDENT INVESTIGATION REPORT.doc ACCIDENT INVESTIGATION REPORT.doc - Alternative Formats
3. After reviewing the case and completing the accident investigation report, on a word document, provide detailed recommendations for improving the safety in the workplace that is featured in the case.

ACCIDENT INVESTIGATION REPORT Company ____________________________ Address ______________________________ Department ___________________ Location (if different from above) _________________

1. Name of Injured 2. Social Security Number 3.Sex (M/F)

4. Age

5. Date of Accident

6. Home Address ___________________________________________

7. Employees Usual Occupation

8. Occupation at Time of Accident

9. Employment Category Regular, full-time Temporary Non-employee Regular, part-time Seasonal

10. Length of Employment Less than 1 mo. 6 mos. to 5 yrs. 1 5 mos. More than 5 yrs.

11. Time in Occupation at Time of Accident Less than 1 mo. 6 mos. to 5 yrs. 1 5 mos. More than 5 yrs.

12. Nature and Injury and Part of the Body ___________________________________________

13. Case Numbers of Others Injured in Same Accident ______________________________ _____________________________ ______________________________ _____________________________ 14. Name and Address of Physician __________________________ __________________________ 15. Name and Address of Hospital __________________________ __________________________ 16. Time of Injury A.M. A. _________________ P.M. B. Time within shift C. Type of Shift 17. Severity of Injury Fatality Lost workdays days away from work Lost workdays days of restricted activity Medical treatment First aid Other, specify ______________ 18. Specific Location of Accident __________________________________________ On Employers Premises? Yes No 19. Phase of Employees Workday at Time of Injury During rest period Entering or leaving plant During meal period Performing work duties Working overtime Other _________________ 20. Describe How the Accident Occurred __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 21. Accident Sequence: Describe in reverse order of occurrence events preceding the injury and accident. Starting with the injury and moving backward un time, reconstruct the sequence of events that led to the injury. A. Injury Event _______________________________________________________________________________________ B. Accident Event _____________________________________________________________________________________ C. Preceding Event #1 ________________________________________