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Accident Incident Report Form

The document is an Accident/Incident Report Form that requires completion immediately after an incident. It includes sections for general information, incident details, injuries or damages, witnesses, actions taken, and additional comments. All sections must be filled out to the best of the reporter's knowledge.

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christian ephraim quilas
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5 views2 pages

Accident Incident Report Form

The document is an Accident/Incident Report Form that requires completion immediately after an incident. It includes sections for general information, incident details, injuries or damages, witnesses, actions taken, and additional comments. All sections must be filled out to the best of the reporter's knowledge.

Uploaded by

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

Please fill out this form as soon as possible after the accident/incident. All sections must be
completed to the best of your knowledge.

1. General Information
Date of Report: ___________________________

Full Name of Reporter: ___________________________

Position/Job Title: ___________________________

Phone Number: ___________________________

Email Address: ___________________________

2. Incident Details
Date of Incident: ___________________________

Time of Incident: ___________________________

Location of Incident: ___________________________

Brief Description of the Incident: ____________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

3. Injuries or Damages
Were there any injuries? (Yes/No): ___________________________

If yes, describe the injuries: ________________________________________________________

_________________________________________________________________________________

Were there any damages? (Yes/No): ___________________________

If yes, describe the damages: ________________________________________________________

_________________________________________________________________________________
4. Witnesses
Were there any witnesses? (Yes/No): ___________________________

If yes, please provide their names and contact information:

Witness 1: ____________________________________________________

Contact Information: __________________________________________

Witness 2: ____________________________________________________

Contact Information: __________________________________________

5. Actions Taken
What actions were taken immediately after the incident? __________________________________

_________________________________________________________________________________

Was emergency services contacted? (Yes/No): ___________________________

6. Additional Comments
Please provide any additional information regarding the incident:
__________________________________________________________________________________

_________________________________________________________________________________

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