Employee Information

  • Name of Employee:

  • Date of Report:

  • Occupation:

  • Dept:

  • Age:

  • Length of Employment:

Accident Information

  • Date and time of Accident:

  • Exact Location:

  • Description of Accident- What was Employee doing?

  • What tools or equipment was he/she using?

  • Witnesses- Names/What they saw or heard and when:

  • Describe extent of Employee's injury:

  • When did Employee report the Accident? Date/Time

  • Did Employee go to a doctor for treatment?

  • At what doctor's location did they go for treatment?

  • Did Employee go to a hospital?

  • What hospital did they go for treatment?

  • If "Other" list name of hospital.

  • Did the Employee return to work after the accident? When?

Accident Information and Follow-up

  • After investigating this accident, was this caused by an unsafe act or unsafe condition?

  • If the answer to preceding question is “Other” please explain.

  • What should be done, and by whom, to prevent this accident from recurring in the future?

  • What are you doing to see that this is done?

  • Were pictures / videos retrieved and turned in?

  • Please include pictures of the accident scene.

  • Signature:

  • Title

  • Date:

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