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Accident Report Form

The document is an accident investigation report form containing details about an employee injury. It includes sections for employee details, injury details, nature and extent of injury, type of incident, witness details, how the accident happened, what caused the accident, how to prevent recurrence, and supervisor details. The form is used to document workplace accidents and injuries for reporting purposes.

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AJAY1381
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Available Formats
Download as DOC, PDF, TXT or read online on Scribd
349 views

Accident Report Form

The document is an accident investigation report form containing details about an employee injury. It includes sections for employee details, injury details, nature and extent of injury, type of incident, witness details, how the accident happened, what caused the accident, how to prevent recurrence, and supervisor details. The form is used to document workplace accidents and injuries for reporting purposes.

Uploaded by

AJAY1381
Copyright
© © All Rights Reserved
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Accident Investigation Report Form

EMPLOYEE DETAILS
Name: ____________________________ Position:_____________________________
Address: _______________________________________________________________
INJURY DETAILS
Date of accident: ___________ Time: ________ Date Reported: __________ Time: _________
Date ceased work: __________ Time: __________ Supervisor: __________________________
Time lost (to date): ___________________ Time lost (anticipated overall) __________________
Medical Treatment required:
_________________________________________________________________________
_____

Nature and extent of injury

Part of body injured

Nature of injury

Type of incident

Head

Trunk

Multiple

Eyes

Arm

General

Neck

Leg

Unspecified

Sprain

Laceration

Burn

Fracture

Concussion

Superficial

Multiple

Dislocation

Amputation

Contusion

Other

Flying object

Manual handling

Electricity

Struck by

Poisons

Fall

Caught in

Temperature

Other

Describe the events leading up to the injury and how the injury occurred (witness or injured
persons statement).

Accident Investigation - Supervisors Report

Witness Details

How did the accident happen

What caused the


accidents

Ineffective
guarding

Lack of protective
equipment

Lack of training

Lack of
maintenance

Safety rules not


followed

inexperience

Unsafe work
methods

Misconduct

Workplace design
(equipment, design,
layout)

Weather

Poor housekeeping

Language
difficulties

Explain

How can a recurrence be prevented?

Supervisors name:
_______________________________________________________
Signature: _____________________________________ Date:
____________________
Appropriate Government/insurance bodies Advised? (If applicable)
Date :_________________________
Is this a Work-related injury?

Yes/No

Yes/No

Accident Investigation - Supervisors Report

Employer/Supervisor Interview Record:

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