Employee Accident/Incident Report

• Date of Accident

  Date
Employee Name
• Normal Work Location
  Address

• Accident / Incident Location

• Weather Conditions

  Select

• Your Job Description

  Select

• List Witnesses

Accident report

• How soon did you report accident / incident to supervision after occurence

• Was This a Motor Vehicle Accident on a public street

  Yes

  No

  N/A

• Was a report filed with Law Enforcement or other Agency

  Yes

  No

  N/A

• Was This Caused By A Third Party

  Yes

  No

  N/A

• Describe

  Yes

  No

  N/A

• In Your Own Words "What Were You Doing prior to the Accident/Incident?"

• How Could This accident \ incident have been prevented

  Select

• Were You Competent/Qualified To Perform The Task Assigned

  Yes

  No

  N/A

• Was There a Written Work Plan In Place And Followed

  Yes

  No

  N/A

Employees Injuries

• Did You Suffer From Any Of The Following Illness/Injury

  Select

• Description of Poison Ingested

• SDS Available

  Yes

  No

  N/A

• SDS Consulted for Treatment / First Aid

  Yes

  No

  N/A

• Description Of Insect/animal

• Description Of Animal

• Body Part/ Area Injured

  Select

• Describe Injury

  Select

• Describe Your Injury

• Description Of Injury

• Photos Of Your Injuries

  Media

• SDS Available

  Yes

  No

  N/A

• SDS Consulted for Treatment / First Aid

  Yes

  No

  N/A

• Descripe Your Injury

• Photos Of Your Injuries

  Media

• Descripe Your Injury

• Photos Of Your Injuries

  Media

• Descripe Your Injury

• Photos Of Your Injuries

  Media

• Descripe Your Injury

• Photos Of Your Injuries

  Media

• Descripe Your Injury

• Photos Of Your Injuries

  Media

• Descripe Your Injury

• Photos Of Your Injuries

  Media

• Descripe Your Injury

• Photos Of Your Injuries

  Media

• SDS Available

  Yes

  No

  N/A

• SDS Consulted for Treatment / First Aid

  Yes

  No

  N/A

• Descripe Your Injury

• Photos Of Your Injuries

  Media

• Descripe Your Injury

• Photos Of Your Injuries

  Media

• Descripe Your Injury

• Photos Of Your Injuries

  Media

• Descripe Your Injury

• Photos Of Your Injuries

  Media

• Descripe Your Injury

• Photos Of Your Injuries

  Media

• Describe The Injury

• If Other Describe Your Injury

• List other employees injured or involved in accident / injury and there tasks or roles if applicable

Type of Medical Treatment you required

• First Aid Only

• CPR Performed

• AED Used

• Did You Require/Request Professional Medical Treatment

  Yes

  No

  N/A

• Where Were You Treated

  Select

• How Were You Transported For Treatment

  Select

• Supervisors Name

• Co-workers Name

• Personals Name

• How Were You Transported For Treatment

  Select

• How Were You Transported For Treatment

  Select

• How Were You Transported For Treatment

  Select

• Was Your Emergency Contact Informed Of Your Accident

  Yes

  No

  N/A

• Did you collect and submit copies of all treatment forms and information to the Safety Dept. as soon as possible

Equipment/Tools Involved

• Equipment/Tools being Used During Accident/Incident

• Was faulty equipment a factor in the accident / incident

  Yes

  No

  N/A

• Describe reason

  Select

PPE

• Was PPE required For The Task You Were Performing

  Select

• List PPE You Were Wearing During The Task You Were Performing

  Select

• If not wearing required and available PPE describe why:

• What could have been done differently or additionally to protect against future occurrences similar to this

• If light Duty is advised by your care provider are you willing to accept it

  Yes

  No

  N/A

• Please provide any additional information you feel is pertinent to this accident / incident, the cause, your injury or your recovery

• Employee Signature

  Sign