Accident/Illness Report

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Employer Information

• Select date

  Date

• Company Name

• Completed by:

• Job Title:

• Phone Number

• Mailing Address

Employee Information

• Full Name

• Job Title

• Hire Date

• Employee Number

• Home Address

• Birthdate

• Gender

  Male

  Female

Physician/Health Care Professional Information

• Name of attending Physician or Health Care Professional

• Location where treatment was given

• Facility Name

• Street Address

• Was Employee Treated in Emergency Room

  Yes

  No

  N/A

• Was employee hospitalized overnight as an in-patient?

  Yes

  No

  N/A

• If yes, length of stay

Incident Information

• Case #

• Date of Incident

  Date

• Time employee began work

  Date

• Time of Incident

  Date

• Date of initial injury/illness diagnosis

  Date

• Number of days away from work

• Number of days of restricted work activity

• Choose one:

  Injury/Illness

  Fatality

• If this incident was a fatality, date of death

  Date

• Note: If a fatality occurred or more than 3 employees were hospitalized, OSHA must be verbally notified within 8 hours.

• Did incident occur on employer's premises?

  Yes

  No

• If yes, where on premises did the incident occur?

• If no, location of incident?

• What was the employee doing just before the incident occurred? (Be as specific as possible. If the employee was using tools, equipment, or materials, name them and specify what the employee was doing with them). Example: "climbing a ladder while carrying painting materials", "daily computer entry"

• Explain how the incident occurred. List the events that resulted in the injury or illness, what happened, how it happened, and name objects and how they were involved.

• Describe the injury/illness. Indicate the part of the body that was affected and h ow it was affected.

• Name the object or substance that directly injured the employee. Example: concrete floor

• Add media

  Media

Witness information

• Name, phone, address

• Name, phone, address

Notification Information and Follow-up

• Has the family been contacted?

  Yes

  No

  N/A

• Date

  Date

• Has the personnel department been contacted?

  Yes

  No

  N/A

• Date

  Date

• Has the State Workers Compensation Agency been contacted?

  Yes

  No

  N/A

• Date

  Date

• Has the companies Workers' Compensation carrier been contacted?

  Yes

  No

  N/A

• Date

  Date

• Has the cause of the injury/illness been corrected?

  Yes

  No

  N/A

• Date

  Date

• Describe future action to be taken, including preventative measures to ensure that such injury/illness does not occur again.

• Completed by

  Sign

• Approved by:

  Sign

• Supervisor on duty:

  Sign

Accident Investigation - Employee Interview

• Company:

• Accident Report Number

• Employee:

• Telephone Number

• Department

• Supervisor

• Accident Location

• Accident Date & Time

  Date

• Report Date & Time

  Date

• The the employee involved in the accident - Briefly explain in your own words the circumstances that led to the accident event. Also include your involvement in the accident. Your comments are important to help determine the causes of the accident and correct any unsafe conditions. Thank you.

• I have written the above statement and certify that it is true to the best of my knowledge.

• Employee Signature

  Sign

• Investigator Signature

  Sign