Title Page
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Client / Site
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Date of Report
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Date and Time of Accident
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Reported By
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Location of Accident
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Witnesses
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INSTRUCTION
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1. Completed accident report forms must be submitted to your Project Manager or Health & Safety Coordinator on the same day as accident occurred, by 6pm.
2. Please provide as much detail as possible in the responses.
3. Add photos and notes by clicking on the paperclip icon.
4. To add a Corrective Measure click on the paperclip icon then "Add Action", provide a description, assign to a member, set priority, and due date.
5. Complete audit by providing digital signature.
Details of the accident
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Nature of Accident
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Scene Inspected
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Inspected By:
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Name(S) of Person Involved
• NAME
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Please specify name
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Work Being Carried Out
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Please take a photo of the area affected (i.e. Body Part or Environment)
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Description of the area or body part affected
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If a major accident - Do not disturb the scene
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Describe how the accident occured (What happened before, during and after the event, including relevant environmental and working conditions)
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Please take a photo of scene / area
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What protection measures were in place at the time of the event (Permit, Briefing, Physical Barriers, PPE)
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What was the immediate cause of the event
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What was the root cause of the event
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What medical treatment was administered (if any please detail)
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Who administered the treatment
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In the case of an environmental accident, what measures were put in place to control the damage?
General Comments and Observations
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Please add additional comments and observations
Completion
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Reporting Employee Name and Signature
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Supervisor Name and Signature
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Manager Name and Signature
