Lumiform / Templates / Occupational Accident Report

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

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

Provide a Drawing if Helpful

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 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.