Free Healthcare Facilities Accident Report Form Template
Healthcare Facilities Accident Report Form
Please fill out this form completely to report a machine-related accident in the workplace.
Employee Information
Name
Job Title
Department
Phone number
Accident Details
Date and Time of Accident
Location
Machine/Equipment Involved
Describe the Incident
Injuries Sustained (if any)
Witness Information
Name
Phone number
Immediate Actions Taken
Was First Aid Administered?
Was the Machine Stopped?
Other Actions Taken
Reporting Employee's Statement
I confirm that the above information is accurate to the best of my knowledge.
Name:
Date:
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