Date and Time of Accident

Site Address

Contractor Name

Company Name

Name of Injured Employee

Department/Team

Supervisor Name

Contact Number

Type of Incident

• Machinery Malfunction

• Fall

• Exposure to Hazardous Material

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

Did you report this to a supervisor?

• Yes

• No

Immediate Actions Taken