Date and Time of Accident

Location

• Office Area

• Conference Room

• Parking Lot]

Name of Employee Involved

Department/Team

Contact Number

Type of Incident

• Slip

• Equipment Issue

• Verbal Altercation

Describe the Accident

Witness Name 1

Phone number

Witness Name 2

Phone number

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Were there any injuries?

• Yes

• No

If yes, please input the details of the injury sustained.

Body Part(s) Affected (if applicable)

First Aid Given?

• Yes

• No

Medical Attention Needed?

• Yes

• No

Other Impact on Work or Workplace

Immediate Actions Taken

Name of Reporting Person

Supervisor/HR Representative Name

Phone Number