Accident Report Form

• 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 in detail

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

  Media

• 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

  Media

• Was equipment, tools being used?

  Yes

  No

• Explain what equipment, tools were being used?

• What caused the event?

• Add supporting evidence of contributing factors

  Media

• Were safety regulations in place and used?

  Yes

  No

  N/A

• What was wrong?

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

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