Accident Report Form (Mantis)

• Name of injured person

• Conducted on

  Date

• Prepared by

• Location
  Address

Injured Person Background

• Name of Injured Person

• Date of Birth

• Telephone Number

• Address

• City

• State

• Zip

• Gender

  Male

  Female

Injury Details

• Date and time of event

  Date
• Exact location of event
  Address

• What part of the body was injured?

• Describe fully how the accident happened?

• Was equipment, tools being used?

  Yes

  No

• Explain what equipment, tools were being used?

• What caused the event?

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

Return To Work

• Was the injured party able to remain at work?

  Yes

  No

  N/A

• When did they return to work?

Witness Statements

• Were there any witnesses?

  Yes

  No

• Add witness

Witness

• Enter witness name

• Contact number

• Witness statement

• Witness signature

  Sign

Emergency Services

• Employee went to doctor/ hospital?

  Yes

  No

• Doctor's Name

• Hospital Name

• Police were called to the scene

  Yes

  No

• Police reference number

Sign off

• Injured person signature

  Sign

• Supervisor signature

  Sign