Accident Report

Company Accident Report

• Document No.

• Company Name

• Conducted on

  Date

• Personnel

Incident Date

• Incident date & time

  Date

Reported By

• Name of person reporting the accident?

Incident Detail

• Injured persons name

• Person type

  Staff

  Contractor

  Student

  Visitor

• Contractor's Name (Where applicable)

• Incident location

• Medical treatment given on the day

Incident Description

• Describe how the accident happened?

Photo's Sketches or Diagrams of the Scene

• Add drawing

  Drawing

• Add media

  Media

Accident Causation

• Describe what caused the accident to happen?

Corrective and Preventative Actions

• Actions taken at the scene?

• Suggest additional actions to prevent recurrence?

• Action By

• Action Date

  Date

Approved By

• Add signature

  Sign

• Date Approved

  Date