Accident Root Cause Analysis Report Form
Document an accident, identify contributing factors, and record corrective actions.
Accident Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Accident Location
*
Accident Type
*
Slip, trip, or fall
Equipment or machinery
Vehicle or transport
Property or facility damage
Other
Describe what happened, including the sequence of events and relevant conditions.
*
What immediate actions were taken after the accident?
Contributing Factors
Procedure or process
Equipment or tools
Work environment
Training or communication
Scheduling or workload
Other
What root cause or causes did the investigation identify?
*
What corrective or preventive actions are recommended?
*
Target Completion Date for Corrective Actions
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Report
Should be Empty: