Lumiform Mobile audits & inspections
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Accident report form

You can use this accident report form to document accidents that have led to hurt workers and persons in the work area, on-site or in the field. Find the main cause of the accident so you can prevent accidents like those from occurring again
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Injured Person Background
Name of hurt person:
Date of birth
Injury Details
Exact time of event:
Location of injury:
Which bodypart was injured? Give a detailed description:
Take a photo of the hurt body part. Attach notes if demanded
What was the worker doing before the accident?
What kind of injury? Give a detailed description:
Give a detailed description about how the accident occurred?
Attach photo of the surrounding environment the employee was before the accident
Did the employee use any equipment or tools?
What lead the accident?
Add helpful photos of contributing factors:
Were there safety regulations in place and were they used?
Suggested precautionary action to take in the future to stop reoccurence.
Witness Statements
Were there any witnesses?
Emergency Services
Did the injured employee/person go to a doctor/ hospital?
Was the police called?
Sign off
Signature of the injured person:
Name and signature of supervisor:
Name and signature of the inspector:
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Please note that this checklist template is a hypothetical appuses-hero example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.
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