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Accident-Report-Form

The document is an Accident Investigation Report Form used to collect details about workplace injuries. It includes sections for employee information, injury specifics, incident description, witness statements, and supervisor comments. The form aims to identify causes of accidents and prevent future occurrences.

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imohammadibrahim11
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4 views

Accident-Report-Form

The document is an Accident Investigation Report Form used to collect details about workplace injuries. It includes sections for employee information, injury specifics, incident description, witness statements, and supervisor comments. The form aims to identify causes of accidents and prevent future occurrences.

Uploaded by

imohammadibrahim11
Copyright
© © All Rights Reserved
Available Formats
Download as 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

□ Head □ Trunk □ Multiple

Part of body injured □ Eyes □ Arm □ General

□ Neck □ Leg □ Unspecified

□ Sprain □ Laceration □ Burn

Nature of injury □ Fracture □ Concussion □ Superficial

□ Multiple □ Dislocation □ Amputation

□ Contusion □ Other

□ Flying object □ Manual handling □ Electricity

Type of incident □ Struck by □ Poisons □ Fall

□ Caught in □ Temperature □ Other

Describe the events leading up to the injury and how the injury occurred (witness or injured
person’s statement).
Accident Investigation - Supervisor’s Report

Witness Details

How did the accident happen

□ Ineffective □ Lack of protective □ Lack of training


guarding equipment
What caused the
accidents □ Lack of □ Safety rules not □ inexperience
maintenance followed

□ Unsafe work □ Misconduct □ Workplace design


methods (equipment, design,
layout)

□ Weather □ Poor housekeeping □ Language


difficulties

Explain

How can a recurrence be prevented?

Supervisor’s name:
_______________________________________________________

Signature: _____________________________________ Date:


____________________

Appropriate Government/insurance bodies Advised? (If applicable) Yes/No

Date :_________________________

Is this a Work-related injury? Yes/No


Accident Investigation - Supervisor’s Report

Employer/Supervisor comments:

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