Employee Information

Name of Employee:

Date of Report:



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.


Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.