(Company Name)
EMPLOYEE ACCIDENT/INJURY REPORT FORM
REPORT #:
Your Name:
Sex: / q M q F / Age:
Date of accident: / Time of accident: / q a.m. q p.m.
Your job title:
Length of experience on job: / (years) / (months)
Address or location where accident occurred (also note the area within facility, if applicable):
Nature of injury and injury type (circle injured body parts below)
Part of the body (i.e. left leg, right ankle, lower back, etc.)
Describe how the accident happened (include the specific job being done, machinery, tools or objects involved):
Was personal protective equipment (PPE) required? / q yes q no
Was it provided? / q yes q no
Was it being used? / q yes q no / If “no,” explain:
Was PPE being used as trained by supervisor or designated trainer? / q yes q no q N/A
If “no,” explain:
Signature (of injured worker) / Date:
(Company Name)
POST-ACCIDENT INVESTIGATION REPORT FORM
Should be completed by Safety Coordinator or Supervisor
REPORT #:
Names of witnesses:
Describe the accident (include the specific job being done, machinery, tools or objects involved and any contributing factors):
Were PPE and any other safe guards required to perform the task when the incident occurred? (i.e. protective eyewear, seatbelts, mechanical guards)
Was employee using them? q yes q no If “no,” explain:
Any other safety rules violated? If yes, explain:
If the injured employee was using equipment, was training provided? q yes q no (If “no,” explain) q N/A
Ultimate cause of the accident (root cause):
Interim correction actions taken to prevent recurrence:
Permanent corrective action recommended to prevent recurrence:
Date of report:
Prepared by:
Status and follow-up action:
Safety Coordinator / Supervisor (Signature) / Date