Business Accident Report Form

This Accident Report Form is designed to capture detailed information regarding incidents within the company for comprehensive analysis and action planning.

I. Incident Information

Date and Time of Incident
Location of Incident
Weather Conditions
Primary Cause of Incident

II. Injured Details

Name of Injured Person
Position/Role
Department
Contact Information
Nature of Injury

III. Witness Information

Name of Witness
Contact Information
Statement

IV. Damage Details

Description of Damage

Estimated Cost of Damage

Property/Equipment Involved

V. Immediate Action Taken

Describe the first aid administered to the injured party.

Specify who was notified immediately following the incident (e.g., supervisor, emergency services).

Detail how the scene was secured to prevent further injury or damage.

VI. Follow-Up Actions

Outline the medical treatment provided to the injured party.

Describe the investigation process conducted to determine the cause of the accident.

List all documentation related to the accident (e.g., photographs, witness statements).

Explain how the incident was communicated to relevant parties within the organization.

VII. Recommendations

Suggest measures to prevent similar incidents from occurring in the future.

Recommend any additional training or education necessary to enhance safety awareness.

VIII. Reporting Authority

Reporting Authority Name Position

Date

For Office Use Only:

Incident Report Number Investigator's Name

Date Assigned

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