Sample Accident/Incident Report Form

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Sample form for your own use (not for reporting to WorkSafe).
a c c i d e n t / i n c i d e n t r e p o r t f o r M
record no:________
Personal details
Name:
Occupation:
Section/Dept:
Date of report:
/
/
Accident/incident details
Date:
Time:
Date reported:
/
/
Location:
Witness:
Reported to whom:
Full accident/incident details – what happened, or in the case of a near miss, what could have happened
Injury – Nature of Injury
Contusion/crush
Burn
Dislocation
Amputation
Laceration/open wound
Superficial injury
Foreign body
Internal injury
Concussion
Sprain/strain
Fracture
Dermatitis
Location of Injury
Head/face
Eye
Internal organs
Hand/fingers
Shoulder/arms
Trunk (other than back)
Hip/leg
Foot/toes
Back
Other (state)
Results of accident
Lost time injury Y / N
No. of days: _____ days
Workers’ compensation Y / N
Treatment received:
First aid
Doctor
Hospital
Damage to equipment/buildings/vehicles etc.
What was damaged?
Extent of damage:
Contributing factors
What were the contributing factors (if any)?
Corrective actions
Immediate actions
What controls can be put in place to prevent this from happening again?
Recommendations for action
Who is to implement these controls/corrective actions?
Date by which action is to be taken
/
/
Signatures
Officer:
HS Rep:
Manager:
Director:
Investigating officer:
Actions completed:
Date:
/
/
Manager:
Sample form for your own use (not for reporting to WorkSafe).
a c c i d e n t / i n c i d e n t r e p o r t f o r M
record no:________
Personal details
Name:
Occupation:
Section/Dept:
Date of report:
/
/
Accident/incident details
Date:
Time:
Date reported:
/
/
Location:
Witness:
Reported to whom:
Full accident/incident details – what happened, or in the case of a near miss, what could have happened
Injury – Nature of Injury
Contusion/crush
Burn
Dislocation
Amputation
Laceration/open wound
Superficial injury
Foreign body
Internal injury
Concussion
Sprain/strain
Fracture
Dermatitis
Location of Injury
Head/face
Eye
Internal organs
Hand/fingers
Shoulder/arms
Trunk (other than back)
Hip/leg
Foot/toes
Back
Other (state)
Results of accident
Lost time injury Y / N
No. of days: _____ days
Workers’ compensation Y / N
Treatment received:
First aid
Doctor
Hospital
Damage to equipment/buildings/vehicles etc.
What was damaged?
Extent of damage:
Contributing factors
What were the contributing factors (if any)?
Corrective actions
Immediate actions
What controls can be put in place to prevent this from happening again?
Recommendations for action
Who is to implement these controls/corrective actions?
Date by which action is to be taken
/
/
Signatures
Officer:
HS Rep:
Manager:
Director:
Investigating officer:
Actions completed:
Date:
/
/
Manager:

Download Sample Accident/Incident Report Form

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