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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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Audit
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
Department
Date of Hire
Start Date of Current Job
Experience with Job Task
Length of Shift (in hrs)
Shift
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
annotation!!!
Please Add a Photo When Applicable
Incident Type
Type of Incident
Please Describe
Incident Analysis
Environment
Please Describe
Team Member
Mark all That Apply
Mark all That Apply
Mark all That Are Applicable
Equipment
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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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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