Accident /incident Reporting form's Sample Copy

Employee’s Incident Report Form

Instructions:   Employees will use this form to report all work-related injuries, illnesses or “near miss” events (which could have caused an injury or illness)—no matter how minor.  This helps to identify and correct hazards before they cause serious injuries.  This form will be completed by employees as soon as possible and given to a supervisor for further action. 

I am reporting a work related:     q Injury     q Illness       q Near miss
Name:
Job Title:
Supervisor:
Have you told your supervisor about this injury/near miss?        q Yes      q No
Date of injury/illness/near miss:		Time of injury/illness/near miss:
Names of witnesses (if any):
Where exactly did it happen?
What were you doing at the time?
Describe step by step what led up to the injury/illness/near miss (continue on the back if necessary):
What could have been done to prevent this injury/illness/near miss?
What parts of your body were injured?  If a near miss, how could you have been hurt?
Did you see a doctor about this injury/illness?                                 q Yes      q No
If yes, whom did you see?	Doctor’s phone number:
Date:	Time:
Has this part of your body been injured before?                                q Yes      q No
If yes, when?	Supervisor:
Employee’s signature:	Date:

Supervisor’s Incident Investigation Form

Name of Injured Person		______________________________________________________________
Date of Birth		______________				Telephone Number				___________________
Address		______________________________________________________________
City		______________				State		___________		Zip	_____________
<> Male        <>Female
What part of the body was injured?  Describe in detail.
____________________________________________________________________________________
____________________________________________________________________________________
What was the nature of the injury?  Describe in detail.
____________________________________________________________________________________
____________________________________________________________________________________
Describe fully how the accident happened. What was employee doing prior to the event? What equipment and tools were being used?
____________________________________________________________________________________
____________________________________________________________________________________
Names of all witnesses:
____________________________________________________________________________________
____________________________________________________________________________________
Date of Event	______________				Time of Event				____________ am     pm
Exact location of event:
____________________________________________________________________________________
____________________________________________________________________________________
What caused the event?
____________________________________________________________________________________
____________________________________________________________________________________
Were safety regulations in place and used? If not, what was wrong?
____________________________________________________________________________________
____________________________________________________________________________________
Employee went to doctor/hospital?			Doctor’s Name:
			Hospital’s Name:
Recommended preventive action to take in the future to prevent reoccurrence:
____________________________________________________________________________________
____________________________________________________________________________________
________________________________________				________________________________________
Supervisor’s Signature				Date

Incident Investigation Report

Instructions:  Complete this form as soon as possible after any incident that an employee reports or which results in serious injury or illness and to investigate a minor injury or near miss that could have resulted in a serious injury or illness.

This is a report of :      q Death     q Lost Time    q Dr. Visit Only    q First Aid Only     q Near Miss
Date of incident:	This report is made by:  q Employee   q Supervisor   q Team q Other_________

Step 1:  Injured employee (complete this part for each injured employee)
Name:	Sex: q Male    q Female	Age:
Department:	Job title at time of incident:
Part of body affected: (shade all that apply)	Nature of injury: (most serious one): q Abrasion, scrapes q Amputation q Broken bone q Bruise q Burn (heat) q Burn (chemical) q Concussion (to the head) q Crushing Injury q Cut, laceration, puncture q Hernia q Illness q Sprain, strain q Damage to a body system: q Other ___________		This employee works: q Regular full time q Regular part time q Seasonal q Temporary
			Months with this company:
			Months doing this job:

  

Step 2:  Describe the incident
Exact location of the incident:	Exact time:
What part of employee’s workday?  q Entering or leaving work  q Doing normal work activities q During meal period  q During break  q Working overtime  q Other___________________
Names of witnesses (if any):

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. Attach separate sheets if necessary.

Step 3:  Why did the incident happen?
Unsafe workplace conditions: (Check all that apply) q Inadequate guard q Unguarded hazard q Defective safety device q Defective tool or equipment q Hazardous workstation layout q Unsafe lighting q Unsafe ventilation q Lack of needed personal protective equipment q Lack of appropriate equipment/tools q Unsafe clothing q No training or insufficient training q Other:__________________________________	Unsafe acts by people: (Check all that apply) q Operating without permission q Operating at unsafe speed q Servicing equipment that has power to it q Making a safety device inoperative q Using defective equipment q Using equipment in an unapproved way q Unsafe lifting q Taking an unsafe position or posture q Distraction, teasing, horseplay q Failure to wear personal protective equipment q Failure to use the available equipment/tools q 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? q Yes   q No  If yes, describe:
Were the unsafe acts or conditions reported prior to the incident?                                    q Yes   q No
Have there been similar incidents or near misses prior to this one?                                  q Yes   q No

Step 4:  How can future incidents be prevented?

What changes do you suggest to prevent this incident/near miss from happening again? q Stop this activity    q Guard the hazard    q Train the employee(s)    q Train the supervisor(s) q Redesign task steps    q Redesign workstation    q Write a new policy/rule    q Enforce existing policy q Routinely inspect for the hazard    q Personal protective equipment    q Other: __________________

What should be (or has been) done to carry out the suggestion(s) checked above? Attach separate sheets if necessary.

Step 5: Who completed and reviewed this form?  (Please Print)
Written by: Department:	Title: Date:
Names of investigation team members:
Does team agree with corrective action recommended in step 4?   Yes   No   N/A (Step 6 should be completed using investigation team’s final recommendations)
Reviewed by:		Title: Date:

Step 6: Corrective Action and Follow-up
Written by: Department:	Title: Date:
List corrective action to be implemented, date completed and responsible parties. 1. ______________________________________________________________________ ______________________________________________________________________ 2. ______________________________________________________________________ ______________________________________________________________________ 3. ______________________________________________________________________ _________________________________________________________________________
Date of follow-up:		Conducted by: