Title Page
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Department
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Full Name of Employee
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Age
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Conducted on (Date and Time)
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Full Name of Supervisor
General Information
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Capture photo of Identification
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Date and time of the incident
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Location of the incident
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Are there other people involved?
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Person/s involved? Click "Add"
Person
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Capture photo of Identification
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Phone Number
Accident Report
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What are the details of the accident?
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Capture photo evidence
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Why did the incident happen?
- Poorly maintained tools or equipment
- Poor housekeeping, slippery floor, or tripping hazards
- Unguarded equipment
- Crowded work condition
- Poor storage practices
- Failure to wear PPE
- Insufficient lighting or ventilation
- Cold or hot temperature
- Others
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Please specify
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Incurred injuries
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Did the employee leave work?
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What are the consequences of the accident?
- Personal injury
- Property loss
- Lost income
- Medical expenses
- Lowered productivity
- Decreased employee moral
- Others
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Please specify
Witness/es
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Are there any witness/es?
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Witness/es? Click "Add"
Witness
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Full Name
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Phone Number
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Statement
Completion
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Recommendations to avoid accident recurrence
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Supervisor Full Name and Signature