Title Page

  • Department of injured person

  • Company name

  • Company name

  • Full Name of Employee

  • Report conducted by

  • Report conducted on (Date and Time)

  • Full Name of Supervisor

  • Proof of site competency (cscs card)

General Information

  • Date and time of the incident

  • Location of the incident
  • Are there other people involved?

  • Person/s involved? Click "Add"

  • Person
  • Capture photo of Identification

  • Phone Number

  • Brief description of incident

  • What immediate action was taken?

Accident Report

  • What are the details of the accident?

  • Capture photo evidence

  • Why did the incident happen?

  • Please specify

  • Incurred injuries

  • Did the employee leave work?

  • How long for?

  • What are the consequences of the accident?

  • Please specify

  • Is there anything that could be put in place to prevent this from happening again?

  • Please specify

Witness/es

  • Are there any witness/es?

  • Witness/es? Click "Add"

  • Witness
  • Full Name

  • Phone Number

  • Statement

Completion

  • Recommendations to avoid accident recurrence

  • Supervisor Full Name and Signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.