Free Equipment Accident Report Form Template
Equipment Accident Report Form
Please complete this form to report any accidents or incidents involving equipment.
Date and Time of Accident
Location (Area)
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Warehouse
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Workshop
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Production Floor
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Reporter Name
Job Title/Role
Company Name
Phone number
Name of Injured Employee
Incident Description
Provide a detailed description of the incident. Include events leading up to, during, and after the occurrence.
Type of Incident
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Equipment Failure
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Electrical Malfunction
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Operator Error
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Moving Parts Hazard
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Witness Name 1
Phone number
Witness Name 2
Phone number
Upload Relevant Files
Type of Equipment Involved
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Forklift
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Conveyor Belt
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Power Tool
Condition of Equipment Before Incident
Were there any injuries?
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Yes
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No
Description of Injuries or Damages
Describe the type and severity of injuries. Specify who was injured and their condition.
Was medical attention provided?
Immediate Actions Taken
Describe actions taken to address the incident, such as shutting down equipment, repairs, or providing aid.
Was the incident reported to a supervisor?
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Yes
-
No
Supervisor Name
Phone Number
Additional Comments
Include any further information, suggestions, or recommendations to prevent future occurrences.
|
Reporter |
[Your Name] Supervisor |
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