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Employee Accident Report Template

An Employee Accident Report form is a crucial document used to record details of any workplace incidents that result in employee injuries. This form helps employers understand what happened, assess risks, and implement safety measures. To ensure a thorough and accurate report, fill out the form by clicking the button below.

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Structure

The Employee Accident Report form serves as a crucial tool in workplace safety management, documenting incidents that occur on the job. This form collects vital information about the accident, including the date, time, and location of the event, as well as the names of those involved and any witnesses present. It also prompts the reporting individual to describe the circumstances surrounding the accident, detailing the actions leading up to the incident and the nature of any injuries sustained. Additionally, the form may include sections for identifying potential safety hazards and suggesting measures to prevent future occurrences. By systematically gathering this information, organizations can analyze trends, implement necessary changes, and enhance overall workplace safety. Ultimately, the Employee Accident Report form not only aids in compliance with regulatory requirements but also fosters a culture of safety and accountability within the workplace.

Instructions on How to Fill Out Employee Accident Report

Completing the Employee Accident Report form is an important step in documenting any workplace incident. This process ensures that all necessary information is collected for proper review and follow-up. Below are the steps to guide you through filling out the form accurately.

Begin by entering your personal information at the top of the form. Include your full name, job title, and department.
Next, provide the date and time of the accident. Be as precise as possible to ensure accurate records.
Describe the location where the incident occurred. Include specific details, such as the building name or area within the workplace.
In the section labeled "Description of Incident," write a clear and concise account of what happened. Include any relevant details that could help in understanding the circumstances of the accident.
If there were any witnesses, list their names and contact information. This information can be crucial for follow-up inquiries.
Indicate if you sought medical attention. If so, provide the name of the medical facility or professional you visited.
Sign and date the form at the bottom. Your signature confirms that the information provided is accurate to the best of your knowledge.

Once you have completed the form, submit it to your supervisor or the designated safety officer. They will review the report and take any necessary action.

Key takeaways

When filling out and using the Employee Accident Report form, keep the following key takeaways in mind:

Complete the form promptly. Fill out the report as soon as possible after the incident to ensure accuracy and detail.
Include all relevant details. Document the date, time, and location of the accident, along with a description of what happened.
List witnesses. If there were any witnesses to the accident, include their names and contact information.
Be factual. Stick to the facts and avoid speculation about causes or blame.
Report injuries. Clearly state any injuries sustained, even if they seem minor at first.
Use clear language. Write in simple, straightforward terms to ensure the report is easily understood.
Submit the report. Ensure the completed form is submitted to the appropriate supervisor or HR representative.
Follow up. Check back to confirm that the report has been received and processed.

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Documents used along the form

When an employee is involved in an accident at work, several forms and documents may come into play alongside the Employee Accident Report. Each of these documents serves a unique purpose, helping to ensure that the incident is thoroughly documented and addressed. Below is a list of commonly used forms that can accompany the Employee Accident Report.

Incident Investigation Report: This document details the circumstances surrounding the accident. It includes witness statements, a timeline of events, and any contributing factors that may have led to the incident.
First Aid Report: If first aid was administered, this form outlines the treatment provided to the injured employee. It records details such as the nature of the injury and the name of the person who provided care.
Workers' Compensation Claim Form: This form is necessary for employees seeking compensation for work-related injuries. It captures essential information about the injury and the circumstances under which it occurred.
Return-to-Work Form: After an employee has recovered, this document is used to assess their readiness to return to work. It may require a healthcare provider's approval and outlines any work restrictions.
Safety Training Records: These records show the safety training that employees have received. They can help determine if the injured employee had the necessary training related to the incident.
Equipment Inspection Report: If equipment was involved in the accident, this report details its condition and any maintenance performed. It helps to identify whether equipment failure contributed to the incident.
Witness Statements: Collected from individuals who witnessed the accident, these statements provide additional perspectives on what occurred and can clarify details in the investigation.
Accident Follow-Up Report: This document is used to track the progress of the injured employee and any follow-up actions taken by the employer in response to the incident.
OSHA 300 Log: Required by the Occupational Safety and Health Administration, this log records work-related injuries and illnesses. It helps employers track safety performance over time.

These documents collectively contribute to a comprehensive understanding of workplace incidents. By utilizing them effectively, organizations can enhance their safety protocols and support employees who may be affected by workplace accidents.

Sample - Employee Accident Report Form

Employee Incident Investigation Report

Instructions: Complete this form as soon as possible after an incident that results in serious injury or illness.

(Optional: Use to investigate a minor injury or near miss that could have resulted in a serious injury or illness.)

This is a report of a: Death Lost Time Dr. Visit Only First Aid Only Near Miss

Date of incident:

This report is made by: Employee Supervisor Team Other_________

Step 1: Injured employee (complete this part for each injured employee)

Name:	Sex: Male Female		Age:

Department:	Job title at time of incident:

Part of body affected: (shade all that apply)	Nature of injury: (most	This employee works:
	serious one)	Regular full time
	Abrasion, scrapes	Regular part time
	Amputation	Seasonal
	Broken bone	Temporary
	Bruise	Months with
	Bruise
	Burn (heat)
	Burn (heat)	this employer
	Burn (chemical)	this employer
	Burn (chemical)
	Concussion (to the head)	Months doing
	Crushing Injury	this job:
	Cut, laceration, puncture
	Cut, laceration, puncture
	Hernia
	Illness
	Sprain, strain
	Damage to a body system:
	Other ___________

Step 2: Describe the incident

Exact location of the incident:

Exact time:


What part of employee’s workday? Entering or leaving work			Doing normal work activities
During meal period	During break	Working overtime Other___________________

Names of witnesses (if any):

Number of attachments:

Written witness statements:

Photographs:

Maps / drawings:

What personal protective equipment was being used (if any)?

Describe, step-by-step the events that led up to the injury. Include names of any machines, parts, objects, tools, materials and other important details.

	Description continued on attached sheets:


Step 3: Why did the incident happen?
Unsafe workplace conditions: (Check all that apply)	Unsafe acts by people: (Check all that apply)
Inadequate guard	Operating without permission
Unguarded hazard	Operating at unsafe speed
Safety device is defective	Servicing equipment that has power to it
Tool or equipment defective	Making a safety device inoperative
Workstation layout is hazardous	Using defective equipment
Unsafe lighting	Using equipment in an unapproved way
Unsafe ventilation	Unsafe lifting
Lack of needed personal protective equipment	Taking an unsafe position or posture
Lack of appropriate equipment / tools	Distraction, teasing, horseplay
Unsafe clothing	Failure to wear personal protective equipment
No training or insufficient training	Failure to use the available equipment / tools
Other: _____________________________	Other: __________________________________

Why did the unsafe conditions exist?

Why did the unsafe acts occur?

Is there a reward (such as “the job can be done more quickly”, or “the product is less likely to be damaged”) that may

have encouraged the unsafe conditions or acts? Yes No If yes, describe:

Were the unsafe acts or conditions reported prior to the incident?	Yes	No

Have there been similar incidents or near misses prior to this one?	Yes	No

Step 4: How can future incidents be prevented?

What changes do you suggest to prevent this incident/near miss from happening again?

	Stop this activity	Guard the hazard	Train the employee(s)	Train the supervisor(s)
	Redesign task steps	Redesign work station	Write a new policy/rule	Enforce existing policy

Routinely inspect for the hazard Personal Protective Equipment Other: ____________________

What should be (or has been) done to carry out the suggestion(s) checked above?

Description continued on attached sheets:

Step 5: Who completed and reviewed this form? (Please Print)

Written by:	Title:
Department:	Date:

Names of investigation team members:

Reviewed by:

Title:

Date:

Dos and Don'ts

When filling out the Employee Accident Report form, it’s important to be thorough and accurate. Here are some dos and don’ts to keep in mind:

Do provide detailed information about the incident, including time, location, and circumstances.
Do include the names and contact information of any witnesses.
Don't leave out any relevant details, as this could affect the investigation.
Don't assign blame or make assumptions about what happened; stick to the facts.