Injury, Accident, Incident Report

• Prepared by

• Reported on

  Date

• Client / Site (if applicable)

• Location of Incident / Accident
  Address

SECTION I

• Name of employee involved

• Date and time of incident

  Date

• Date and time incident was reported.

  Date

• To whom was the incident / accident reported?

• Location of incident

• Was there any witness(es)? If yes, provide name(s) and contact number(s).

  Yes

  No

  N/A

DETAILS OF INJURY, IF APPLICABLE

• Was the injury caused in a road traffic accident - if yes, please state registration

  Yes

  No

  N/A

• Describe injury.

• Severity of injury.

  Minor

  Serious

  Major

• Detail any first-aid or medical treatment administered on site - Provide names

• Were the emergency services called

  Yes

  No

  N/A

• Did you attend hospital - if yes, please state which one

  Yes

  No

  N/A

DETAILS OF DAMAGE, IF APPLICABLE

• Item Damaged:

  N/a

  Vehicle

  Equipment

  Private Property

• Severity of Damage:

  Minor

  Serious

  Major

• Description of damage - also include as much detail as possible about how it happened

• Environmental photo - if vehicle accident

  Media

• Immediate (Direct Causes):

ANALYSIS

• Contributing (underlying) Factors:

• Corrective Action (Include detail description of action and person(s) responsible for actions)

• What is the probability of reoccurrance?

  Remote

  Improbable

  Probable

• Signature

  Sign