Stephanie Camilleri

Accident Report Form

Use this accident injury report form to record accidents that have led to injured employees and persons in the workplace, on-site or in the field. Find the root cause of the incident so you can prevent accidents from happening again

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Title Page

Name of injured person
Conducted on
Prepared by
Location

Injured Person Background

Name of Injured Person
Telephone Number

Injury Details

Date and time of event
What part of the body was injured? Describe in detail
Describe fully how the accident happened?
What was the employee doing prior to the event?
Was equipment, tools being used?
Explain what equipment, tools were being used?
What caused the event?
Were safety regulations in place and used?
Recommended preventive action to take in the future to prevent reoccurence

Witness Statements

Were there any witnesses?
Add witness
Enter witness name
Contact number
Witness statement
Witness signature

Emergency Services

Employee went to doctor/ hospital?
Police were called to the scene

Sign off

Injured person signature
Supervisor signature

Stephanie Camilleri

Accident Report Form

Use this Template

Print as PDF

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.