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Accident Report

An employee accident report form documents an incident involving a worker. It collects information such as the employee's name and ID number, the date and time of the accident, what occurred, and the supervisor's investigation into the cause and how similar accidents could be prevented going forward. Witnesses are also listed. Both the employee and supervisor sign upon completing the report.

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Wearechange Utah
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© Attribution Non-Commercial (BY-NC)
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103 views

Accident Report

An employee accident report form documents an incident involving a worker. It collects information such as the employee's name and ID number, the date and time of the accident, what occurred, and the supervisor's investigation into the cause and how similar accidents could be prevented going forward. Witnesses are also listed. Both the employee and supervisor sign upon completing the report.

Uploaded by

Wearechange Utah
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as PDF, TXT or read online on Scribd
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ACCIDENT REPORT

EMPLOYEE
EMPLOYEE NAME POSITION

SOC. SEC. NO. DEPARTMENT

EMPLOYEE ID NO. SUPERVISOR

ACCIDENT INFORMATION
DATE OF OCCURRENCE TIME AM LOCATION
PM
DESCRIBE ACTIVITY PRIOR TO ACCIDENT

WHAT HAPPENED (DESCRIBE CAUSE AND OBJECT OF INJURY)

I CERTIFY BY MY SIGNATURE THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND COMPLETE.
EMPLOYEE SIGNATURE DATE

SUPERVISOR SECTION
WHEN DID YOU FIRST LEARN OF THE ACCIDENT

BASED ON YOUR INVESTIGATION, WHAT WAS THE CAUSE OF THE ACIDENT

HOW COULD THIS ACCIDENT HAVE BEEN PREVENTED?

WHAT ACTIONS HAVE BEEN TAKE TO AVOID FUTURE ACCIDENTS OF THIS TYPE?

WITNESSES: (NAME, ADDRESS, PHONE)

SUPERVISOR SIGNATURE DATE

©2005 CARDINAL BRANDS, INC. PERSONNEL FORMS ON CD 32345

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