Free Accident and Injury Report Form Template

Accident and Injury Report Form

Please fill out this form to report an accident.

Incident Details

Date of Incident

    Location of Incident

      Type of Incident

        • Slip/Fall

        • Equipment Malfunction

        • Physical Injury

        Description of Incident

          Injured Party Details

          Name of Injured Party

            Position/Department

              Phone number

                Injury Details

                Body Parts Affected

                  Incident Description

                    Safety Improvements or Corrective Measures Suggested

                      Declaration

                      I certify that the information provided in this report is true and accurate to the best of my knowledge.

                      Date:

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