• Prepared by

  • Conducted on

Site details

  • Location of Incident

  • Site that employee was working at;

Accident/Incident Details

  • Date and time of injury;

  • Employee Name

  • Job Title:

  • Nature of Incident or Injury

  • Describe who, what, when,where, why and how injury occurred:

  • Contributing causes of the Incident: (Inadequate training, Inadequate supervision. Employee not following proper safety procedures and instructions)

  • Possible Cause or Causes of the incident: (Inadequate PPE, Not Paying attention to surroundings, failure to utilise safety equipment)

  • What is the employee's current status if injured: Describe. ( Returned to work the next day, off of work do to injury, off of work do to restrictions, In hospital, etc.)

Supervision details

  • Was Risk Assessment completed before work began:

  • Facility Safety Office Informed?

  • Date and Time when the employer was notified:

Injured Party statement

  • Name & Signature of the injured party

Witness statements

  • Witnesses 1

  • Name and signature of the witness 1

  • Witnesses 2

  • Name and signature of the witness 2

  • Witnesses 3

  • Name and signature of the witness 3

Injury Details if Applicable

  • Where was the Medical treatment first provided?

  • Provider Doctor Details

  • Part of Body injured:

  • Image of injury

  • Will the employee have any restrictions:

Action: Short Term

  • What was the immediate action taken to correct the issue (how was this done):

Action: Long Term

  • What is the long term action needed to correct the issue:

Additional Information

  • Lessons Learned:

  • Please provide all attachments that apply: Pictures, Drawings, Training Records, Statement of Employee, Statement of Witness/es, Other.

Person Completing Form (please sign below)

  • Is the above report a true reflection of the Accident / Incident

Supervisor in Charge (please sign below)

  • Is the above report a true reflection of the Accident / Incident

Injured Party witnessing the completion of the forms agreement with the content and that it is a true reflection of the accident / Incident

  • Is the above report a true reflection of the Accident / Incident

  • Injured employee has received Workers Compensation DWC-1 report

  • Add 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.