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Fill in a Valid Employee Accident Report Form

The Employee Accident Report form is a crucial document used to record details of workplace accidents and injuries. This form helps employers track incidents, ensuring compliance with safety regulations and providing essential information for future prevention. Understanding how to fill out and utilize this form effectively can enhance workplace safety and promote a culture of accountability.

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Example - 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:

Documents used along the form

In the event of an employee accident, several forms and documents are often utilized alongside the Employee Accident Report form. Each document serves a specific purpose in documenting the incident, ensuring compliance, and facilitating follow-up actions. Below is a list of common forms that may be required.

Incident Report Form: This form provides a detailed account of the circumstances surrounding the accident, including witness statements and environmental factors.
Medical Treatment Authorization: This document grants permission for medical professionals to provide treatment to the injured employee.
Workers' Compensation Claim Form: Employees use this form to formally request compensation for medical expenses and lost wages resulting from the accident.
Return to Work Form: This form is completed by the healthcare provider to confirm that the employee is fit to return to work after treatment.
Safety Inspection Report: This report assesses the workplace conditions and identifies any hazards that may have contributed to the accident.
Hold Harmless Agreement: To further protect parties involved, the essential Hold Harmless Agreement form resources provide legal safeguards against liability during events or activities.
Witness Statement Form: Witnesses to the accident can provide their accounts through this form, which helps clarify the events that took place.
Accident Follow-Up Report: This document outlines any actions taken post-incident to prevent future occurrences and improve workplace safety.
Incident Investigation Report: A thorough investigation report that analyzes the root causes of the accident and recommends corrective actions.
Training Records: Documentation of any relevant safety training the employee received, which may be pertinent to the accident investigation.

Utilizing these documents in conjunction with the Employee Accident Report form can help ensure a comprehensive approach to managing workplace incidents. Proper documentation not only aids in compliance but also promotes a safer work environment for all employees.