TRAFFIC ACCIDENT INVESTIGATION REPORT

1. GENERAL DATA OF THE WORK CENTER

1.1 COMPANY NAME: 1.2 MAIN ACTIVITY OF THE COMPANY:

1.3 ISIC: 1.4 NO. WORKERS:

1.6.1 PARISH/CANTON
1.6 MAIN STREET/NUMBER/INTERSECTION. GEOGRAPHIC REFERENCES OF LOCATION:

1.7 NAME OF LEGAL REPRESENTATIVE 1.7.1 EMAIL

1.8 NAME OF THE PERSON RESPONSIBLE FOR SAFETY 1.8.1 EMAIL

AT WORK:

1.9 NAME OF THE PERSON RESPONSIBLE FOR 1.9.1 EMAIL

OCCUPATIONAL HEALTH:

2. WORKER'S DATA
2.1 WORKER'S NAME 2.2 AGE 2.3 GENDER 2.4 INSTRUCTION
2.4.1 NONE ( )
2.4.2 BASIC ( )
2.4.3 AVERAGE ( )
2.6 CITIZENSHIP CARD 2.7 MARITAL STATUS 2.8 MAIN STREET/NUMBER/INTERSECTION.
GEOGRAPHIC REFERENCES OF LOCATION.

2.11 WORK EXPERIENCE 2.12 CONTRACTED WORK ACTIVITY.

2.14 WORKING HOURS

REGULAR ( ROTATIVE ()

3. DATA OF THE WORK ACCIDENT

3.2 STREET OR ROAD

3.1 SITE AT THE COMPANY OR PLACE OF THE ACCIDENT :

3.3 CITY: 3.4 DATE OF ACCIDENT 3.5 HOURS

3.7 PERSONS INTERVIEWED

3.7.1 NAME : 3.7.2 CHARGE :

3.7.3 NAME : 3.7.4 CHARGE :

3.7.5 NAME : 3.7.6 CHARGE :

3.8 RESEARCH DATE

4. DETAILED DESCRIPTION OF THE ACCIDENT

4.1 AGENTS OR MATERIAL ELEMENTS OF THE ACCIDENT

4.1.1 Agent or Material Element of the Accident:

4.1.2 Part of the Agent

4.2 SOURCE OR ACTIVITY DURING THE ACCIDENT

4.3 CONTACT TYPE ANALYSIS

4.4 CONSEQUENCES OF THE ACCIDENT

5. CAUSALITY ANALYSIS
5.1 DIRECT CAUSES:
5.1.1 SUBSTANDARD CONDITIONS:

5.1.2 SUBSTANDARD STOCK:

5.2 INDIRECT CAUSES:

5.2.1 WORK FACTORS:

5.2.2 WORKER FACTORS:

5.3 ROOT CAUSES:

5.3.1 Hazard identification; measurement, evaluation and control of risks. Cu
5.3.2 Occupational environmental and worker health surveillance. Cu
5.3.3 Investigation of occupational or occupational accidents and diseases Cu
5.3.4 Personal protective equipment and work clothes. Cu
5.3.5 Worker education, training, and training Cu
5.3.6 Integral operational control. Cu
6. CORRECTIVE ACTIONS
6.1 ROOT CAUSE CORRECTIVE ACTIONS.

6.2 CORRECTIVE ACTIONS FOR INDIRECT CAUSES (WORK FACTORS AND WORKER FACTORS).

6.3 CORRECTIVE ACTIONS FOR DIRECT CAUSES (SUBSTANDARD CONDITIONS AND ACTIONS).

7. IDENTIFICATION OF THE RESEARCH

7.1 NAME(S) OF INVESTIGATOR(S) 7.2 PROVINCIAL UNIT OF OCCUPATIONAL RISKS.
UNDER

1.5 RUC

1.6.2 CITY 1.6.3 PROVINCE

1.7.2 CELLULAR PHONE

1.8.2 CELLULAR PHONE

1.9.2 CELLULAR PHONE

2.5 EMPLOYMENT
2.4.4 HIGHER ( ) RELATIONSHIP
2.5.1 TEMPLATE IF ( )
NO ( )
2.4.5 FOURTH LEVEL
()

2.9 TELEPHONE 2.10 CELL

2.13 WORK ACTIVITY PERFORMED.

FROM (hh:mm) UNTIL (hh:mm)

A O SECTOR:

3.6 DATE OF RECEIPT OF IESS

mple YES ( ) NO ( )
mple YES ( ) NO ( ) mple YES ( ) NO ( ) NO ( )
No table of contents entries found.
7.3 DATE OF DELIVERY OF THE REPORT.