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Occupational Accident Report

This document needs to be completed by the team supervisor after a workplace accident has occurred. In order to stay in compliance, this report must be returned within 72 hours of incident. The template will cover the following area:

  • • Team member information
  • Incident information
  • • Incident type
  • • Incident analysis
  • • Preventative measures
  • • Signature and sign off

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Occupational Accident Report


Team Member- Basic Information

(A) Perspective Report #
(B) Team Member Name ( Last, First, MI)
(C) Date and Time of Incident
(D) Date Incident Reported
Employment Status
Regular Job
Job Employee was Performing
Date of Hire
Start Date of Current Job
Experience with Job Task
Length of Shift (in hrs)
Shift Start Time
Type of Shift
Team Member Days Off

Incident Information

Incident Type
Exact Location of Incident (if off property, give address)
Equipment or Materials Involved
Contact Agent (the exact object/material that caused injury)
Describe the Incident
Provide a Drawing if Helpful
Please Add a Photo When Applicable

Incident Type

Type of Incident
Please Describe

Incident Analysis

Please Describe
Team Member
Mark all That Apply
Mark all That Apply
Mark all That Are Applicable
Please Describe
Management (Must have at least one checked)
Please Describe

Preventive Measures

What Action Has Been Taken or Is Planned to Prevent Recurrence
Please Describe
How Will the Above Action(s) Improve Operations?

Signature and Review

NOTE: I have reviewed this report. I am confident that the incident was thoroughly analyzed and proper actions have been taken or are planned to be taken to prevent a recurrence.
Analysis by (Immediate Supervisor)
Team Member Involved
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