Witness Accident/Incident Report

• Date/Time Of Accident

  Date

• Conducted By

• Project

• Location
  Address

• Weather Conditions

  Select

• Was This A Vehicle Accident

  Yes

  No

  N/A

• Was Law Enforcement Contacted

  Yes

  No

  N/A
Employee Injured

• Employee Job Description

  Select

• Witnesses

• In Your Own Words What Did You See Before/During This Accident\Incident

• How Could This Incident/Accident Have Been Prevented

  Select

• In Your Own Words What Could Of Pervented This Accident

Employees Injuries

• Did The Employee Suffer From Any Of The Following Illness/Injury

  Select

• Description Of Poison Ingested

• Description Of Insect/animal

• Description Of Animal

• Body Part The Emplyee Was Injured

  Select

• Describe Injury

  Select

Medical

• First Aid Only

• CPR Performed

• AED Used

• Was Treatment Required/Requested

  Yes

  No

  N/A

Equipment/Tools Involved

• Equipment/Tools Used During Accident/Incident

• PPE Available For The Tasks Being Performed

  Select

• PPE Worn During The Tasks Being Performed

  Select

• Was The Injured Employee Competent/Qualified To Perform The Task Assigned

  Yes

  No

  N/A

• Witness Signature

  Sign