Employee Accident and Incident Report

Document what happened when something goes wrong on the job: the injury, the location, the task under way, and the corrective measures taken. Gives safety teams the detail they need to investigate causes and stop repeat events.

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Was this an Incident or an Accident?

Date

Employee Name

First Name

Last Name

Investigated/Report completed by Name

First Name

Last Name

Date of incident/Accident

Time of incident/Accident

Location

What (injury, nature and body part)

What (was the area conditions)

Where (actual location of incident/Accident)

Which (which task was being performed at the time of the incident/Accident?)

Which (Which type Movement was being used at the time)

Description of Incident/Accident

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Employee Explanation/Notes

Witnesses (were there any and if so do you have statements?)

Witness/Witnesses Names

What immediate containment measures have we put in place to prevent re occurrence?

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