Information

  • Location

  • Conducted on

  • Address

Accident/Incident Report

  • Is the injured an employee or non-employee?

Employee

  • Name of Injured:

  • Phone#:

  • Address of injured:
  • Describe injury or property damage

  • Please attach any photos here

  • Describe accident/incident and how it occurred:

  • Witnesses:

  • Date and Time of accident/incident:

  • Medical attention provided to injured?

  • Please immediately contact Andre' Tarrance @ 904-412-8317, or your direct supervisor for a medical referral and instructions.

  • If medical attention is needed later, then you must first contact your direct supervisor or Andre' Tarrance @904-412-8317 prior to seeking medical attention. A claim and referral must be created prior to seeking medical treatment.

  • Please have employee sign

Non-Employee

  • Name of Injured:

  • Phone#:

  • Address of injured:
  • Sex:

  • Describe injury or property damage.

  • Please attach any photos here

  • Describe accident/incident and how it occurred:

  • Were there any goods or equipment that caused the accident? I.e. Broken chair

  • Please verify that the item is in the managers office.

  • Please attach photo of item.

  • Witnesses:

  • Date and Time of accident/incident:

  • Is the injured individual 18 or older?

  • Please provide the name of the parent or guardian.

  • What is the age of the injured?

  • Medical attention above general first aid provided to injured?

  • Please immediately contact Andre' Tarrance @ 904-412-8317

  • Comments:

  • Prepared by:

  • Title:

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.