PFM - Accident Report Form

• Audit Title

• Conducted on

  Date

• Prepared by

• Who was injured?

  Customer

  Employee

Customer Accident Report

• Date and Time of Incident

  Date

• Location of Incident

• Camera View

• Name of Injured Person

• Address

• City/State

• Zip

• Phone Number

• Injured Persons Description of What Happened

• DESCRIPTION OF THE ALLEGED INJURY

• WAS MEDICAL ATTENTION GIVEN TO ALLEGED INJURED PARTY?

  Yes

  No

• Please Explain

• WHAT CAUSED THE ALLEGED ACCIDENT?

• DESCRIBE ALLEGED INCIDENT

• Are there any witnesses?

  Yes

  No

• Witness Name

• Contact Number

• Address - Street

• City

• State

• Zip

• Reported By:

• Title:

• Contact #:

• Department:

• Date/Time this report was completed:

  Date

Employee Accident Report

• Name

• Job Title

• Accident occur on premises?

  Yes

  No

• Accident Location

• Date & Time of Injury

  Date

• Sex:

  Male

  Female

• Date Reported

  Date

• Are there witnesses?

  Yes

  No

• Witness Name

• Witness Contact Information

• Witness Description

• Accident Description

Injured Area

• Where did the employee allegedly get inured?

  Select Head Eye Shoulder Arm Elbow Wrist Hand Finger Back Chest Abdomen Hip Leg Knee Ankle Foot Toe Other

  • Head
  • Eye
  • Shoulder
  • Arm
  • Elbow
  • Wrist
  • Hand
  • Finger
  • Back
  • Chest
  • Abdomen
  • Hip
  • Leg
  • Knee
  • Ankle
  • Foot
  • Toe
  • Other

• What was injured?

• Which finger(s)

  Select Pinky finger Ring finger Middle finger Index finger Thumb

  • Pinky finger
  • Ring finger
  • Middle finger
  • Index finger
  • Thumb

• Left, right or both side(s)?

  Select Left side Right side

  • Left side
  • Right side

Type of Injury

• What is the type of injury?

  Select Abrasion Amputation Bite Bruise Burn Concussion Cut/Laceration Foreign Body Fracture Hearing Impaired Infection Pain Puncture Rash Respiratory Strain/Sprain Other

  • Abrasion
  • Amputation
  • Bite
  • Bruise
  • Burn
  • Concussion
  • Cut/Laceration
  • Foreign Body
  • Fracture
  • Hearing Impaired
  • Infection
  • Pain
  • Puncture
  • Rash
  • Respiratory
  • Strain/Sprain
  • Other

• What other type of injury?

• Did injured employee miss work?

  Yes

  No

• Started missing work

  Date

• Returned back to work

  Date

• Form completed by:

• Form completion date

  Date

• Supervisor's Signature:

  Sign

Investigation Report

• Cause of Accident

• Source of Accident

  Select Bitten by: Human/Animal Caught Between/In/On/Under Contact by with Chemical/Electricity/Other Equipment Involved: Exposure To: Slip/Trip/Fall Falling/Flying Object Handling Materials Standing on: Ladder/Step Stool/Other Struck By: Vehicle Accident Other:

  • Bitten by: Human/Animal
  • Caught Between/In/On/Under
  • Contact by with Chemical/Electricity/Other
  • Equipment Involved:
  • Exposure To:
  • Slip/Trip/Fall
  • Falling/Flying Object
  • Handling Materials
  • Standing on: Ladder/Step Stool/Other
  • Struck By:
  • Vehicle Accident
  • Other:

• Please describe in more detail.

• Corrective Action

• Action Taken

  Select House Keeping Improved Office Arrangement Changed Safety Equipment Purchased Replace Furniture or Equipment Training for employees Maintenance and Upkeep Plan Safety Committee Referral Other

  • House Keeping Improved
  • Office Arrangement Changed
  • Safety Equipment Purchased
  • Replace Furniture or Equipment
  • Training for employees
  • Maintenance and Upkeep Plan
  • Safety Committee Referral
  • Other

• Please describe in more detail.

• Did the employee violate a safety policy?

  Yes

  No

• Was the employee disciplined in any way?

  Yes

  No

• What was the disciplinary action?

• Why wasn't the employee disciplined?

• What safety policy did the employee violate?

• How many times has the employee violated this safety policy?

  1st Offence

  2nd Offence

  3rd Offence

  4th Offence