Workplace Accident Report Form
Internal Incident & Corrective Action Log
Incident Date:
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INCIDENT INVESTIGATION REPORT
Company: Acme Manufacturing | Location: Warehouse 3
Report ID: INC-2025-001 | Report Date: ---
1. Incident Details
Employee Name (Victim)
Jane R. Doe
Incident Date/Time
MM/DD/YYYY @ HH:MM
Department / Job Title
Assembly Line / Technician
Shift / Hours Worked
Day / 6 hours
2. Narrative and Injury Classification
Summary of Events:
Employee tripped over an unsecured power cable while carrying materials.
Injury Type: Sprain/Strain
Body Part Affected: Right Ankle
Medical Treatment: First Aid Administered (Ice, Bandage)
3. Root Cause & Corrective Action
Root Cause Analysis:
Root cause was poor housekeeping (cable management). Secondary cause: inadequate lighting in aisle.
Corrective Actions Taken:
Cable was secured immediately with caution tape. Maintenance was dispatched to repair lighting.
4. Signatures & Review
Witness(es): John D., Sarah K.
Injured Employee Signature
Supervisor / Manager Signature
Safety Officer / HR Review