Accident/Incident Details

  • Employee Name

  • Date and time of injury;

  • Department

  • Machine Accident Happened (please be specific)

  • What is Severity of the Incident?

  • Severity:

  • If Injured Give Details

  • Part of Body injured:

  • Picture of Injury if Applicable:

  • What type of provider performed treatment?

  • Cause or Causes of the incident:

  • Picture of Contributing Causes:

Supervision details

  • Was Supervisor Notified?

  • Tap to enter information
  • Name of Supervisor?

Injured Party statement

  • Name & Signature of the injured party

Witness statements

  • Was there a Witness?

  • Tap to enter information
  • How Many?

  • Tap to enter information
  • Witness 1 Statement:

  • Witness 1 Signature

  • Tap to enter information
  • Witness 1 Statement:

  • Witness 1 Signature

  • Witness 2 Statement:

  • Witness 2 Signature

  • Tap to enter information
  • Witness 1 Statement:

  • Witness 1 Signature

  • Witness 2 Statement:

  • Witness 2 Signature

  • Witness 3 Statement:

  • Witness 3 Signature

Corrective Actions

Action: Short Term

  • What was the immediate action taken to correct the issue (how was this done):

  • Who was the responsible party for correcting the issue:

Action: Long Term

  • What is the long term action needed to correct the issue:

  • Who was the responsible party for correcting the issue:

Investigation Conclusions

Person Completing Form (please sign below)

  • Is the above report a true reflection of the Accident / Incident

Supervisor in Charge (please sign below)

  • Is the above report a true reflection of the Accident / Incident

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