Information

ATTENTION Prior to filling out this Accident Report: 1. Secure the scene of the accident 2. Provide treatment 3. Call for emergency services if necessary 4. Take pictures of the scene

  • Name of Injured Employee

  • Client / Site

  • Conducted on

  • Prepared by

INSTRUCTIONS

  • 1. Provide immediate medical attention if necessary. Call Carl or Payroll immediately to authorize treatment/drug testing. Drug/Alcohol test is required for all employee injuries.

    2. Within 8 hours, complete this form and the form: 'Root Cause Analysis (Fishbone)' for all job related injuries AND near misses.

    3. Whenever possible, the foreman and the injured employee will sign the form.

INFORMATION ABOUT THE INJURED

  • Name

  • Sex

  • Date of Hire

  • Date of Birth

  • Home Address

  • Phone

  • Social Security Number

  • Job Title

  • What time did the Employee begin work?

  • Did the Employee leave work?

  • What time?

  • Did the Employee return to work?

  • What time?

  • Did you authorize medical treatment?

  • Have restrictions been given?

  • How long?

  • Describe restrictions

  • Is there light duty work available?

  • Fatality?

  • CALL CARL IMMEDIATELY!

  • Were three or more employees injured?

  • CALL CARL IMMEDIATELY!

  • Drug/alcohol test?

  • THIS IS REQUIRED. CALL MAIN OFFICE IF YOU HAVE ANY QUESTIONS.

INFORMATION ABOUT THE ACCIDENT

  • Date and time of the accident

  • Date accident is being reported

  • JOB INFORMATION

  • Location Name

  • Describe specific location of incident on job site

  • Job Number

  • Address
  • Foreman

  • Describe what happened and probable cause of accident

  • no label
  • Select location of injury and answer the appropriate questions.

  • Describe nature of injury

  • Side

  • Provide pictures of the scene

  • Name of physician and hospital where treated

  • Name and phone number of Witness #1

  • Name and phone number of Witness #2

  • Foreman's Signature

  • Injured Employee's Signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.