Accident/Injury/Incident Report

• Notified Management/EMS

  Date

• Conducted on

  Date

• Prepared by

• Site
  Address

• Document

• NOTE:
  This general template can be used for all incidents, however it is important to check with your state regulatory body requirements and/or Insurer as to the legal reporting requirements. You can modify this template to suit your workplace needs.

Incident Details

• Enter job description

• Date and time of incident

  Date

• Detailed description of incident

• What was the Incident/Near Miss/Reportable?

• Were there any injuries?

  Yes

  No

• Description of injury

• Take photo of injury

  Media

• Was there any damage to property or plant?

  Yes

  No

• Description of damage

• Take photo of damage

  Media

• What caused the incident?

• Take photo of surrounding environment including any annotations

  Media

• What actions will be taken to eliminate future repeats of the incident?

• Was proper PPE being worn for the job?

• Management comments

• Any witnesses or others involved in incident?

Employee Injury/Illness

• Name/Last 4 Digits of Social/Date of Birth

• Date of Hire

  Date

• Occupation Title

• Part of Body Injured

• Equipment/Object/Element

• Person with most control of object/equipment/etc.

• Job or Activity at Time of Accident

• Time working at Task or Location

• Loss Severity Potential - Minor, Serious, Major

• Probable Recurrence Rate - Frequent, Occasional, Rare

Sign Off

• Injured/Incident/Accident Person Signature

• Injured/Incident/Accident Person sign off

  Sign

• Injured/Incident/Accident Person Sign off

  Sign

• Signed off by supervisor when corrective actions have been adopted and monitored

• Management/Supervisor sign off

  Sign

• Signatures of witnesses/persons involved

• Witnesses/Persons involved

  Sign