Employee Incident/Accident Report Form
Was this an Incident or an Accident?
Incident
Accident
Date
-
Month
-
Day
Year
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Employee Name
First Name
Last Name
Investigated/Report completed by Name
First Name
Last Name
Date of incident/Accident
-
Month
-
Day
Year
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Time of incident/Accident
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Location
What (injury, nature and body part)
N/A
Ankle
Arm
Foot
Hand
Head
Groin
Knee
Neck
Shoulder
Back
Chest
Knee
What (was the area conditions)
Tidy, well lit, no obstructions.
Rubbish, debris, general untidiness.
Restricted space.
Ice, sleet, snow, Freezing
Where (actual location of incident/Accident)
Van
Customers House
Warehouse
Racking
Engineering area
Office area
Yard
Road
Which (which task was being performed at the time of the incident/Accident?)
Unloading
Loading
Picking
Packing
Put away
Driving
Administration
Computer work
Engineering work
Which (Which type Movement was being used at the time)
Twisting
Turning
lifting
bending
walking
Stepping
repetitive movement
Description of Incident/Accident
Download Picture Here
Browse Files
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of
Employee Explanation/Notes
Witnesses (were there any and if so do you have statements?)
Yes
No
Witness/Witnesses Names
What immediate containment measures have we put in place to prevent re occurrence?
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