Accident Report Form

Documents the details of an accident or incident that occurred on site, including witnesses and actions taken, for use in insurance claims.

Use this template

Report Type

Accident Incident Near miss

Time

Date

Reporting Facility

Name of Participant / Injured Party

First Name

Last Name

Age of Participant / Injured Party

Name of Parent / Guardian (if applicable)

First Name

Last Name

Phone Number

Staff Completing Form

First Name

Last Name

Phone Number

Area Where Accident/Incident Occurred

Description of Incident

Action Taken / Treatment Administered

Witness 1

First Name

Last Name

Witness 2

First Name

Last Name

Follow-Up Action (if applicable)

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