Templates
Accident report form

Accident report form

Use this form to record accidents at work that have resulted in injured employees and persons at the workplace, on the construction site or in the field.

Use this template
or download pdf
Accident report form

Use this form to record accidents at work that have resulted in injured employees and persons at the workplace, on the construction site or in the field.

Use this template
or download pdf

About the 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

Categories

  • Incident management templates
  • Workforce management and HR templates
  • Workplace safety templates
Preview of the template
Audit
Injured Person Background
Name of hurt person:
Date of birth
Address:
City:
State:
Telephone:
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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This template, developed by Lumiform employees, serves as a starting point for businesses using the Lumiform platform and is intended as a hypothetical example only. It does not replace professional advice. Companies should consult qualified professionals to assess the suitability and legality of using this template in their specific workplace or jurisdiction. Lumiform is not liable for any errors or omissions in this template or for any actions taken based on its content.