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Employee Accident Report Form

The Employee Accident Report form is a document used to record details of workplace incidents involving employees. This form captures essential information about the accident, including the nature of the injury, the circumstances surrounding the event, and any witnesses present. Proper completion of this report is crucial for ensuring workplace safety and compliance with legal requirements.

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Employee Accident Report Sample

Employee Incident Investigation Report

Instructions: Complete this form as soon as possible after an incident that results in serious injury or illness.

(Optional: Use to investigate a minor injury or near miss that could have resulted in a serious injury or illness.)

This is a report of a: Death Lost Time Dr. Visit Only First Aid Only Near Miss

Date of incident:

This report is made by: Employee Supervisor Team Other_________

Step 1: Injured employee (complete this part for each injured employee)

Name:	Sex: Male Female		Age:

Department:	Job title at time of incident:

Part of body affected: (shade all that apply)	Nature of injury: (most	This employee works:
	serious one)	Regular full time
	Abrasion, scrapes	Regular part time
	Amputation	Seasonal
	Broken bone	Temporary
	Bruise	Months with
	Bruise
	Burn (heat)
	Burn (heat)	this employer
	Burn (chemical)	this employer
	Burn (chemical)
	Concussion (to the head)	Months doing
	Crushing Injury	this job:
	Cut, laceration, puncture
	Cut, laceration, puncture
	Hernia
	Illness
	Sprain, strain
	Damage to a body system:
	Other ___________

Step 2: Describe the incident

Exact location of the incident:

Exact time:


What part of employee’s workday? Entering or leaving work			Doing normal work activities
During meal period	During break	Working overtime Other___________________

Names of witnesses (if any):

Number of attachments:

Written witness statements:

Photographs:

Maps / drawings:

What personal protective equipment was being used (if any)?

Describe, step-by-step the events that led up to the injury. Include names of any machines, parts, objects, tools, materials and other important details.

	Description continued on attached sheets:


Step 3: Why did the incident happen?
Unsafe workplace conditions: (Check all that apply)	Unsafe acts by people: (Check all that apply)
Inadequate guard	Operating without permission
Unguarded hazard	Operating at unsafe speed
Safety device is defective	Servicing equipment that has power to it
Tool or equipment defective	Making a safety device inoperative
Workstation layout is hazardous	Using defective equipment
Unsafe lighting	Using equipment in an unapproved way
Unsafe ventilation	Unsafe lifting
Lack of needed personal protective equipment	Taking an unsafe position or posture
Lack of appropriate equipment / tools	Distraction, teasing, horseplay
Unsafe clothing	Failure to wear personal protective equipment
No training or insufficient training	Failure to use the available equipment / tools
Other: _____________________________	Other: __________________________________

Why did the unsafe conditions exist?

Why did the unsafe acts occur?

Is there a reward (such as “the job can be done more quickly”, or “the product is less likely to be damaged”) that may

have encouraged the unsafe conditions or acts? Yes No If yes, describe:

Were the unsafe acts or conditions reported prior to the incident?	Yes	No

Have there been similar incidents or near misses prior to this one?	Yes	No

Step 4: How can future incidents be prevented?

What changes do you suggest to prevent this incident/near miss from happening again?

	Stop this activity	Guard the hazard	Train the employee(s)	Train the supervisor(s)
	Redesign task steps	Redesign work station	Write a new policy/rule	Enforce existing policy

Routinely inspect for the hazard Personal Protective Equipment Other: ____________________

What should be (or has been) done to carry out the suggestion(s) checked above?

Description continued on attached sheets:

Step 5: Who completed and reviewed this form? (Please Print)

Written by:	Title:
Department:	Date:

Names of investigation team members:

Reviewed by:

Title:

Date:

⇓ PDF File

Instructions on Utilizing Employee Accident Report

Completing the Employee Accident Report form is essential for documenting any workplace incidents. Follow these steps carefully to ensure all necessary information is provided accurately.

Begin by entering the date and time of the accident in the designated fields.
Provide your name and contact information, including your job title and department.
Describe the location of the accident. Be specific about where it occurred.
Detail the events leading up to the accident. Include any relevant circumstances or actions that contributed to the incident.
List any witnesses to the accident. Include their names and contact information.
Explain the nature of the injury sustained. Be clear and concise in your description.
Indicate whether medical treatment was received. If so, provide details about the treatment and the name of the medical provider.
Sign and date the form at the bottom to confirm that the information provided is accurate.

Once the form is completed, submit it to your supervisor or the designated personnel as instructed. This will ensure that the report is processed in a timely manner.

Misconceptions

When it comes to the Employee Accident Report form, several misconceptions can lead to confusion among employees and employers alike. Understanding the truth behind these myths can help ensure that the reporting process is handled correctly and efficiently. Here are seven common misconceptions:

The report is only for serious accidents. Many believe that only major incidents require documentation. However, all accidents, regardless of severity, should be reported to ensure proper records and safety improvements.
Filing a report will lead to punishment. Some employees fear that reporting an accident will result in disciplinary action. In reality, the purpose of the report is to promote safety and prevent future incidents, not to assign blame.
Only supervisors can fill out the form. While supervisors often assist with the process, any employee involved in an accident has the right to complete the report. This helps ensure accurate information is captured.
The form is only for workplace injuries. Many think that the report only applies to injuries sustained on company property. However, it can also cover incidents that occur while performing work-related duties off-site.
Once submitted, the report is never reviewed. Some employees assume that their reports disappear into a void. In fact, these reports are typically reviewed by management to improve workplace safety and address any concerns.
Witness statements are not necessary. While not always required, witness accounts can provide valuable context. Including them can strengthen the report and help clarify the circumstances of the accident.
There is no deadline for filing the report. Many believe they can take their time submitting the form. However, most companies have specific timelines for reporting accidents to ensure timely responses and investigations.

By addressing these misconceptions, employees can feel more confident in navigating the Employee Accident Report process. Open communication about reporting can lead to a safer workplace for everyone.

Documents used along the form

When an employee experiences an accident at work, several important forms and documents come into play alongside the Employee Accident Report form. These documents help ensure that the incident is properly documented, investigated, and addressed. Below is a list of commonly used forms that may accompany the Employee Accident Report.

Incident Report Form: This form provides a detailed account of the accident, including the circumstances, location, and any witnesses. It helps gather all relevant information in one place.
Durable Power of Attorney Form: This legal document allows individuals to appoint someone to make decisions on their behalf, particularly regarding financial and healthcare matters, ensuring their wishes are respected, even during incapacitation. For those seeking to secure their future, filling out this form is essential. All Washington Forms
Witness Statement Form: Collected from individuals who witnessed the incident, this form captures their observations and insights, which can be crucial for understanding what happened.
Medical Treatment Authorization Form: If the injured employee requires medical attention, this form grants permission for healthcare providers to treat the employee and share medical information with the employer.
Workers' Compensation Claim Form: This form is necessary for employees seeking benefits related to their injury. It outlines the details of the accident and the nature of the injury.
Return to Work Release: After treatment, this document is issued by a healthcare provider, indicating that the employee is fit to return to work and outlining any necessary accommodations.
Safety Inspection Report: Conducted after the accident, this report assesses the workplace for safety hazards that may have contributed to the incident, helping to prevent future accidents.
Accident Investigation Report: This comprehensive report analyzes the accident's causes and recommends measures to improve workplace safety and avoid similar incidents in the future.
Training Records: Documentation of safety training provided to employees can be useful in understanding whether proper protocols were followed leading up to the incident.
Employee Statement Form: This form allows the injured employee to provide their own account of the incident, offering their perspective on what occurred.
HR Incident Follow-Up Form: Used by human resources to track the progress of the incident investigation and any actions taken in response to the accident.

Each of these documents plays a vital role in addressing workplace accidents. Together, they help create a clear picture of the incident, ensuring that all necessary steps are taken to support the affected employee and enhance workplace safety. Proper documentation can lead to improved policies and a safer environment for everyone.