FICHA DE ANLISE

DE ACIDENTES
COMISSO INTERNA DE
PREVENO DE ACIDENTES

HORA ______:______

DATA

_______/_______/_______.

NOME DO ACIDENTADO

IDADE

FUNO

DEPARTAMENTO

SEO

DADOS DO ACIDENTE
DESCRIO DO ACIDENTE:

____________________________________________________

___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________.
PARTE DO CORPO ATINGIDA:

____________________________________________________

___________________________________________________________________________________.
INFORMAO DO ENCARREGADO:

______________________________________________

______________________________________________
______________________________________________
______________________________________________

________________________
ASS. DO ENCARREGADO

INVESTIGAO DO ACIDENTE
COMO OCORREU:

_____________________________________________________________

___________________________________________________________________________________
___________________________________________________________________________________.
CAUSA APURADA:

_____________________________________________________________

______________________________________________
______________________________________________
______________________________________________

___________________________
ASS. MEMBRO DA COMISSO

CONCLUSO DA COMISSO
CAUSA DO ACIDENTE:

_____________________________________________________________

___________________________________________________________________________________
___________________________________________________________________________________.
RESPONSABILIDADE:

_____________________________________________________________

___________________________________________________________________________________.
MEDIDAS PROPOSTAS: _____________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________.

___________________
ASS. SECRETARIA (O)

__________________
ASS. PRESIDENTE

FICHA DE ANLISE
DE ACIDENTES
SERVIO DE SEGURANA

HORA

_____ :_____

DATA:

DO TRABALHO
NOME DO ACIDENTADO

IDADE

FUNO

DEPARTAMENTO

SEO

DADOS DO ACIDENTE
DESCRIO DO ACIDENTE:

____________________________________________________

___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________.
PARTE DO CORPO ATINGIDA:

____________________________________________________

___________________________________________________________________________________.
INFORMAO DO ENCARREGADO:

______________________________________________

______________________________________________
______________________________________________
______________________________________________

________________________
ASS. DO ENCARREGADO

COMO OCORREU:

INVESTIGAO DO ACIDENTE
_____________________________________________________________

___________________________________________________________________________________
___________________________________________________________________________________.
CAUSA APURADA:

_____________________________________________________________

___________________________________________________________________________________
__________________________________________________________________________________.
CONCLUSO
CAUSA DO ACIDENTE:

_____________________________________________________________

___________________________________________________________________________________
___________________________________________________________________________________.
RESPONSABILIDADE:

_____________________________________________________________

___________________________________________________________________________________
MEDIDAS PROPOSTAS: _____________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________.

___________________
SUPERVISOR REA

_____________________
SEGURANA DO TRABALHO