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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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Accident report form


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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