Date and Time of Accident

Location

• Office

• Construction Site

• Common Area

Name of Injured Employee

Role

• Employee

• Visitor

• Contractor

Contact Number

Type of Incident

• Slip

• Equipment Failure

• Hazardous Substance Exposure

Witness Name 1

Phone number

Witness Name 2

Phone number

Description of Incident

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Were there any injuries?

• Yes

• No

Description of Injuries or Damages

Body Part(s) Affected (if applicable)

First Aid Given?

• Yes

• No

Medical Attention Needed?

• Yes

• No

Immediate Actions Taken

Responsible Staff Member Name

Equipment or Hazard Secured?

• Yes

• No

Health and Safety Officer Name

Phone Number

Additional Notes or Recommendations