Title Page

  • Department

  • Full Name of Employee

  • Age

  • Conducted on (Date and Time)

  • Full Name of Supervisor

General Information

  • Capture photo of Identification

  • 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

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?

  • What are the consequences of the accident?

  • Please specify


  • Are there any witness/es?

  • Witness/es? Click "Add"

  • Witness
  • Full Name

  • Phone Number

  • Statement


  • 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.