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Download Employee Accident Report Template

The Employee Accident Report form is a crucial document used by organizations to record details of workplace accidents. This form helps ensure that incidents are documented accurately, promoting safety and accountability. By collecting information about what happened, where it happened, and who was involved, employers can take steps to prevent future accidents.

Open Employee Accident Report Editor

Download Employee Accident Report Template

Content Overview

The Employee Accident Report form plays a crucial role in workplace safety and compliance. This document is designed to capture essential details about any accidents or incidents that occur on the job. Typically, it includes sections for the date and time of the accident, the names of the individuals involved, and a description of the events leading up to the incident. Additionally, it often requires information about the location where the accident took place and any witnesses present. Employers use this form not only to document the incident but also to analyze trends and implement safety measures to prevent future occurrences. By ensuring that all relevant information is recorded accurately, the form helps facilitate a thorough investigation and supports workers' compensation claims if necessary. Overall, it serves as an important tool for promoting a safe working environment and protecting both employees and employers from potential liabilities.

Key takeaways

When filling out and using the Employee Accident Report form, there are several important points to keep in mind.

The form should be completed as soon as possible after the accident occurs to ensure accuracy.
All relevant details, including the date, time, and location of the accident, must be included.
Witness information should be documented, including names and contact information.
Clear descriptions of the incident and any injuries sustained are essential for proper record-keeping.
Submitting the form promptly can help facilitate any necessary follow-up actions, such as medical treatment.
Keep a copy of the completed report for personal records and future reference.

These steps will help ensure that the process is handled efficiently and effectively.

Guide to Writing Employee Accident Report

Completing the Employee Accident Report form is essential for documenting any workplace incident. This report will be reviewed by your employer to ensure proper follow-up and support. Follow these steps carefully to ensure accuracy and completeness.

Start with your personal information. Enter your name, job title, and employee ID.
Provide the date and time of the accident. Be as precise as possible.
Describe the location of the incident. Include specific details about where it occurred.
Detail the nature of the accident. Explain what happened in clear, concise language.
List any witnesses to the incident. Include their names and contact information if available.
Indicate any injuries sustained. Specify the type and severity of injuries.
Sign and date the form. Your signature confirms the information is accurate to the best of your knowledge.

Once you have completed the form, submit it to your supervisor or the designated person in your organization. Timely submission is crucial for proper handling of the incident.

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Form Preview Example

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

When an employee is involved in an accident at work, several forms and documents may be necessary to ensure proper reporting and follow-up. These documents help in documenting the incident, assessing any injuries, and facilitating communication between the employee, employer, and insurance providers.

Incident Report Form: This document provides a detailed account of the accident, including the time, location, and circumstances surrounding the event. It is often filled out by a supervisor or a witness to the incident.
Witness Statement: A witness statement collects information from individuals who observed the accident. Their accounts can provide additional context and support the findings of the incident report.
Sample Tax Return Transcript Form: A vital document that provides detailed insights into an individual's tax filings, capturing income and adjustments comprehensively, which can be crucial for resolving discrepancies related to work-related claims. For further reference, visit smarttemplates.net.
Medical Report: If the employee seeks medical attention, a medical report from a healthcare provider outlines the nature of the injuries and any recommended treatment. This document is crucial for determining the next steps in the employee's recovery.
Workers' Compensation Claim Form: This form is submitted to initiate a claim for benefits related to work-related injuries. It includes details about the accident and the employee's medical treatment.
Return to Work Form: Once the employee has recovered, this form is used to confirm their ability to return to work. It may include any necessary restrictions or accommodations needed for their job duties.
Safety Inspection Report: Following the accident, a safety inspection report may be conducted to assess the workplace conditions. This document identifies any hazards that need to be addressed to prevent future incidents.

These documents collectively support the process of addressing workplace accidents, ensuring that all necessary information is captured and communicated effectively. Proper documentation is vital for the well-being of the employee and the overall safety of the workplace.