Scribd
Upload
22 views3 pages

Accident Report Form

The document is an Accident Report Form used to collect essential details about workplace accidents, including the date, time, location, type of incident, and persons involved. It also captures injury details, causes of the accident, and corrective actions taken. The form requires signatures from the injured person, witnesses, and supervisors to validate the report.

Uploaded by

husnimubarackofficial
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
22 views3 pages

Accident Report Form

The document is an Accident Report Form used to collect essential details about workplace accidents, including the date, time, location, type of incident, and persons involved. It also captures injury details, causes of the accident, and corrective actions taken. The form requires signatures from the injured person, witnesses, and supervisors to validate the report.

Uploaded by

husnimubarackofficial
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
You are on page 1/ 3

ACCIDENT REPORT FORM

Company Name: __________________________


Location/Site: __________________________
Department: __________________________
Date of Report: ____ / ____ / ______
Reported By: __________________________
Contact Number: __________________________

1. Accident Details
 Date of Accident: ____ / ____ / ______
 Time of Accident: __________ AM / PM
 Location of Accident: ____________________________________
 Type of Incident:
☐ Fall from Height
☐ Slip/Trip
☐ Caught in/Between
☐ Struck by Object
☐ Electrical
☐ Chemical Exposure
☐ Fire/Explosion
☐ Other (Please specify): _______________________

2. Persons Involved
Name of Injured Person: __________________________
Designation/Job Title: __________________________
Gender: ☐ Male ☐ Female
Age: ______
Employee ID (if applicable): ____________________
Contact Number: ____________________

3. Description of the Accident


Provide a detailed description of what happened (include sequence of events):
4. Injury Details
 Type of Injury:
☐ Bruise
☐ Cut/Laceration
☐ Fracture
☐ Burn
☐ Sprain/Strain
☐ Internal Injury
☐ Eye Injury
☐ Other: ____________________
 Body Part Affected: __________________________
 First Aid Given: ☐ Yes ☐ No
If yes, specify treatment: __________________________
 Hospitalization Required: ☐ Yes ☐ No
 Name of Hospital (if applicable): __________________________

5. Witnesses (if any)


Name Contact Number Statement Taken (Yes/No)

6. Cause of the Accident


Describe the root cause(s):

☐ Unsafe Act
☐ Unsafe Condition
☐ Lack of PPE
☐ Inadequate Training
☐ Poor Housekeeping
☐ Equipment Failure
☐ Others (Specify): ____________________
7. Corrective/Preventive Actions Taken
Actions Taken Immediately After the Accident:

Recommendations to Prevent Recurrence:

Responsible Person: __________________________


Target Completion Date: ____ / ____ / ______

8. Supervisor/Manager Comments

9. Signatures
Injured Person (if applicable): ________________________ Date: ____ / ____ / ______
Witness (if applicable): ____________________________ Date: ____ / ____ / ______
Supervisor/Manager: ____________________________ Date: ____ / ____ / ______
Safety Officer: ____________________________ Date: ____ / ____ / ______

You might also like