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"

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"


Full Name

Phone Number



Recommendations to avoid accident recurrence

Supervisor Full Name and Signature
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.