Accident Report Form Record No:
Student Name: …………………………….………………..…………………….….. ID:…………………………..……..
Specialty: ……………………………..………………….…. COHORT/Group NO.:..……………………….….……
Location: ………………………………………………………………….…….……. Date: ……………………….…………
Signature: …………………………………………………………....................................................................
Personal Details (Name of injured person)
Name: ............................................................ Relationship to work: ..................................
Position: ......................................................... ID: ...............................................................
Accident Details
Date of accident: .... / .... / 20
Time: : AM / PM
Location: ....................................................................................................................................
The address of the workplace where the accident occurred.
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Nature and extent of injury:
• Part of body injured:
Head☐, Eyes☐, Face☐, Neck☐, Back☐, Spine☐, Chest☐, Abdomen☐, Shoulder☐, Arm☐,
Elbow☐, Hand☐, Finger ☐, Knee☐, Leg☐, Ankle☐, Foot☐, Toe☐, Other…………………………..
• Nature of injury
Sprain☐, Burn☐, Fracture☐, Concussion☐, Superficial☐, Multiple☐, Dislocation☐,
Amputation☐, Bruise☐, Other..................................................................................................
• Type of incident
Flying object☐, Manual handling☐, Electricity☐, Struck by☐ Poisons☐, Slip☐, Trip☐, Fall☐,
Temperature☐, Sharps☐, Traffic Accident☐, Other……………………………………………………………..
Detailed description of the accident: .......................................................................................
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Accident causes: Ineffective guarding☐, Lack of PPE☐, Lack of training☐, Poor maintenance☐,
Safety rules not followed☐, Inexperience☐, Unsafe work methods☐, Misconduct☐, Workplace
design☐, Weather☐, Poor Housekeeping☐, Language difficulties☐, Other……….…………………
Details of reasons: .....................................................................................................................
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Immediate actions: ....................................................................................................................
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Medical Treatment required: None First Aid Hospital
General condition of the casualty: .............................................................................................
Witness Details: .........................................................................................................................
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Corrective Procedures used to prevent the recurrence of accidents:
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Reported By Received By
Name: Name:
ID: ID:
Position: Position:
Date: Date:
Signature: Signature:
Trainer Comments:
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Trainer Signature:
