Workplace Accident Report Form
Workplace Accident Report Form
Please fill out this form to provide details of the accident.
General Information
Date and Time of Report
Reporting Person
Position
Accident Information
Date and Time of Accident
Location of Accident
Accident Description
Provide a description of the accident, how it occurred, and any contributing factors.
Was anyone injured?
If yes, provide details of the injured person(s):
Injured Person(s) Details
Name
Injury Description
Was emergency medical treatment required?
If yes, describe the treatment
(e.g., first aid, hospital)
Witness Information
Are there any witnesses to the accident?
If yes, please provide details:
Name
Position
Phone number
Equipment/Property Damage
Was there any equipment/property damage?
If yes, specify the equipment/property
Damage Description
Additional Information
Provide any additional context or information that may be helpful in reviewing the accident.
Acknowledgement
By signing below, I confirm that the information provided is accurate to the best of my knowledge.
Name:
Date:
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Thank you for your cooperation!
We will review and ensure proper follow-up actions are taken.
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