ABCDEFGHIJKLMNOPQRSTUVWXYZ
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CONSTRUCTION ACCIDENT REPORT
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REPORT CONTROL & PROJECT DETAILS
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Accident numberRevision number
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StatusConfidentiality
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Project nameProject number
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Accident dateAccident time
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Exact locationReported by
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Reported toReport date
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ACCIDENT CLASSIFICATION
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Accident typeAccident category
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Event severityPotential severity
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High potentialInjury
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IllnessWork stoppage
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PEOPLE & WITNESSES
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Primary person involved
Employer / role
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Witness summary
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ACCIDENT DESCRIPTION
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Accident titleAccident description
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Sequence of events
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Actual consequence
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EMERGENCY RESPONSE & WORK RESUME
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Immediate response summary
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Area secured
Emergency services contacted
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First aid completed
Work-resume approval required
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Work-resume approval
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INJURY, DAMAGE & ENVIRONMENTAL SUMMARY
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Injury / medical summary
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Environmental / utility summary
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INVESTIGATION & CONTRIBUTING FACTORS
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Investigation lead
Investigation start date
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Investigation completion date
Root-cause approval status
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Root-cause statement
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CORRECTIVE ACTIONS & LESSONS LEARNED
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Immediate corrective actions
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Effectiveness review
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REFERENCES, APPROVAL & CLOSURE
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Supporting references
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Supervisor reviewer
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Management reviewer
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Approval dateClosure date
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Closure notes
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