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Accident Report Form

The document provides templates for an accident report form with sections for an employee report and supervisor report. The employee report collects details about the injured employee, the injury, treatment, and events leading up to the injury. The supervisor report requires the supervisor to identify witness details, how the accident happened, what caused it, and how to prevent recurrence. The forms are used to document accidents for investigation and to develop procedures to prevent future accidents.

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yenni miranda
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198 views

Accident Report Form

The document provides templates for an accident report form with sections for an employee report and supervisor report. The employee report collects details about the injured employee, the injury, treatment, and events leading up to the injury. The supervisor report requires the supervisor to identify witness details, how the accident happened, what caused it, and how to prevent recurrence. The forms are used to document accidents for investigation and to develop procedures to prevent future accidents.

Uploaded by

yenni miranda
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Accident Report Form

01 WHAT IS AN ACCIDENT REPORT FORM?


All accidents are considered as incidents. However, an accident report form focuses more on
the injury whereas the incident report form is intended to focus on the cause and prevention of
further occurrences.
The Accident Report Form is in 2 parts. The first part is completed by the employee who
suffered the accident, and the second part is completed by the supervisor.
An accident report is an important tool used to document the accident and assist in investigating
the cause. It also assists to develop procedures that may be put in place to prevent it from
happening again.
The supplied template calls on the employee(s), with the assistance of a manager, to fill in the
first page details including:
✓ employee details
✓ injury details- including date, time and expected time off work
✓ medical treatment required
✓ events leading up to the injury- this is important to gain the employees perspective of what
actually happened.

02 SUPERVISOR’S REPORT
The second section of the form is to be completed by the manager and requires the manager to
identify the following:
✓ witness details
✓ how the accident happened
✓ how a recurrence can be prevented.
It is important to show outcomes of the investigation and to document what actions can or will
be taken to prevent another injury occurring in a similar scenario.
The Manager should decide whether or not the accident should also be documented as an
incident needing further investigation. This may well be the case depending on the cause of the
accident and the possibility of it happening again due to job design, system or procedural faults
needing additional investigation and control.
Should your company decide to merge both the accident and incident form together into one
document then the suitability of this should be assessed at senior management level to ensure
that a detailed and documented approach to both matters is still achieved.

NOTE: The template provided can be used for all accidents. However, it is important to
check with your state regulatory body requirements and/or your company Insurer about the
legal requirements for reporting “serious and notifiable incidents”.
Accident Investigation Report Form
EMPLOYEE DETAILS

Name: ____________________________ Position:_____________________________

Address: _______________________________________________________________

INJURY DETAILS

Date of accident: ___________ Time: ________ Date Reported: __________ Time: _________

Date ceased work: __________ Time: __________ Supervisor: __________________________

Time lost (to date): ___________________ Time lost (anticipated overall) __________________

Medical Treatment required:


______________________________________________________________________________

Nature and extent of injury

☐ Head ☐ Trunk ☐ Multiple

Part of body injured ☐ Eyes ☐ Arm ☐ General

☐ Neck ☐ Leg ☐ Unspecified

☐ Sprain ☐ Laceration ☐ Burn

Nature of injury ☐ Fracture ☐ Concussion ☐ Superficial

☐ Multiple ☐ Dislocation ☐ Amputation

☐ Contusion ☐ Other

☐ Flying ☐ Manual handling ☐ Electricity


object
Type of incident
☐ Struck by ☐ Poisons ☐ Fall

☐ Caught in ☐ Temperature ☐ Other

Describe the events leading up to the injury and how the injury occurred (witness or injured
person’s statement).
Accident Investigation - Supervisor’s Report
Witness Details

How did the accident happen?

What caused the ☐ Ineffective ☐ Lack of protective ☐ Lack of training


accidents guarding equipment

☐ Lack of ☐ Safety rules not ☐ Inexperience


maintenance followed

☐ Unsafe work ☐ Misconduct ☐ Workplace design


methods (equipment, design,
layout)

☐ Weather ☐ Poor ☐ Language


housekeeping difficulties

Explain

How can a recurrence be prevented?

Supervisor’s name: _______________________________________________________

Signature: _____________________________________ Date: ____________________

Appropriate Government/insurance bodies Advised? (If applicable) Yes/No

Date :_________________________

Is this a Work-related injury? Yes/No


Accident Investigation - Supervisor’s Report

Employer/Supervisor comments:

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