Title Page

  • Name of injured person

  • Conducted on

  • Prepared by

  • Location

Injured Person Background

  • Name of Injured Person

  • Date of Birth

  • Telephone Number

  • Address

  • City

  • State

  • Zip

  • Gender

Injury Details

  • Date and time of event

  • Exact location of event
  • What part of the body was injured? Describe in detail

  • Take photo of the body part that was injured. Annotate as required

  • What was the nature of the injury? Describe in detail

  • Describe fully how the accident happened?

  • What was the employee doing prior to the event?

  • Take photo of the surrounding environment the employee was in prior to the event

  • Was equipment, tools being used?

  • Explain what equipment, tools were being used?

  • What caused the event?

  • Add supporting evidence of contributing factors

  • Were safety regulations in place and used?

  • What was wrong?

  • Recommended preventive action to take in the future to prevent reoccurence

Witness Statements

  • Were there any witnesses?

  • Add witness

  • Witness
  • Enter witness name

  • Contact number

  • Witness statement

  • Witness signature

Emergency Services

  • Employee went to doctor/ hospital?

  • Doctor's Name

  • Hospital Name

  • Police were called to the scene

  • Police reference number

Sign off

  • Injured person signature

  • Supervisor 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.