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Blank Employee Accident Report Form

The Employee Accident Report form is a crucial document used to record details of workplace accidents and injuries. This form helps ensure that incidents are properly documented, allowing for necessary follow-up actions and improvements in workplace safety. To enhance safety measures and support affected employees, it's important to fill out this form accurately and promptly.

Take the first step towards a safer workplace by clicking the button below to complete the Employee Accident Report form.

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Table of Contents

The Employee Accident Report form plays a crucial role in workplace safety and accountability. This document is designed to capture essential details about incidents that occur on the job, ensuring that both employers and employees have a clear understanding of what transpired. It typically includes sections for the date and time of the accident, the location, and a description of the events leading up to the incident. Additionally, it often requires information about the individuals involved, including witnesses, and any injuries sustained. By documenting these aspects, the form helps organizations analyze patterns and implement safety measures to prevent future occurrences. Moreover, it serves as a vital tool for filing insurance claims and complying with legal requirements, making it an integral part of workplace safety protocols.

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Dos and Don'ts

When filling out an Employee Accident Report form, it's essential to be thorough and accurate. Here’s a list of things you should and shouldn’t do:

Do provide a clear and detailed description of the incident.
Do include the date, time, and location of the accident.
Do list any witnesses and their contact information.
Do document any injuries sustained, no matter how minor.
Don't leave out any relevant details, even if they seem insignificant.
Don't use vague language; be specific about what happened.
Don't forget to sign and date the report before submitting it.

Following these guidelines can help ensure that the report is complete and useful for any necessary follow-up actions.

Employee Accident Report Sample

Employee Incident Investigation Report

Instructions: Complete this form as soon as possible after an incident that results in serious injury or illness.

(Optional: Use to investigate a minor injury or near miss that could have resulted in a serious injury or illness.)

This is a report of a: Death Lost Time Dr. Visit Only First Aid Only Near Miss

Date of incident:

This report is made by: Employee Supervisor Team Other_________

Step 1: Injured employee (complete this part for each injured employee)

Name:	Sex: Male Female		Age:

Department:	Job title at time of incident:

Part of body affected: (shade all that apply)	Nature of injury: (most	This employee works:
	serious one)	Regular full time
	Abrasion, scrapes	Regular part time
	Amputation	Seasonal
	Broken bone	Temporary
	Bruise	Months with
	Bruise
	Burn (heat)
	Burn (heat)	this employer
	Burn (chemical)	this employer
	Burn (chemical)
	Concussion (to the head)	Months doing
	Crushing Injury	this job:
	Cut, laceration, puncture
	Cut, laceration, puncture
	Hernia
	Illness
	Sprain, strain
	Damage to a body system:
	Other ___________

Step 2: Describe the incident

Exact location of the incident:

Exact time:


What part of employee’s workday? Entering or leaving work			Doing normal work activities
During meal period	During break	Working overtime Other___________________

Names of witnesses (if any):

Number of attachments:

Written witness statements:

Photographs:

Maps / drawings:

What personal protective equipment was being used (if any)?

Describe, step-by-step the events that led up to the injury. Include names of any machines, parts, objects, tools, materials and other important details.

	Description continued on attached sheets:


Step 3: Why did the incident happen?
Unsafe workplace conditions: (Check all that apply)	Unsafe acts by people: (Check all that apply)
Inadequate guard	Operating without permission
Unguarded hazard	Operating at unsafe speed
Safety device is defective	Servicing equipment that has power to it
Tool or equipment defective	Making a safety device inoperative
Workstation layout is hazardous	Using defective equipment
Unsafe lighting	Using equipment in an unapproved way
Unsafe ventilation	Unsafe lifting
Lack of needed personal protective equipment	Taking an unsafe position or posture
Lack of appropriate equipment / tools	Distraction, teasing, horseplay
Unsafe clothing	Failure to wear personal protective equipment
No training or insufficient training	Failure to use the available equipment / tools
Other: _____________________________	Other: __________________________________

Why did the unsafe conditions exist?

Why did the unsafe acts occur?

Is there a reward (such as “the job can be done more quickly”, or “the product is less likely to be damaged”) that may

have encouraged the unsafe conditions or acts? Yes No If yes, describe:

Were the unsafe acts or conditions reported prior to the incident?	Yes	No

Have there been similar incidents or near misses prior to this one?	Yes	No

Step 4: How can future incidents be prevented?

What changes do you suggest to prevent this incident/near miss from happening again?

	Stop this activity	Guard the hazard	Train the employee(s)	Train the supervisor(s)
	Redesign task steps	Redesign work station	Write a new policy/rule	Enforce existing policy

Routinely inspect for the hazard Personal Protective Equipment Other: ____________________

What should be (or has been) done to carry out the suggestion(s) checked above?

Description continued on attached sheets:

Step 5: Who completed and reviewed this form? (Please Print)

Written by:	Title:
Department:	Date:

Names of investigation team members:

Reviewed by:

Title:

Date:

Listed Questions and Answers

What is the purpose of the Employee Accident Report form?
The Employee Accident Report form is designed to document any incidents that occur in the workplace, where an employee is injured or experiences an accident. This form helps ensure that all details of the incident are recorded accurately, which can be crucial for safety evaluations, workers' compensation claims, and legal compliance.
Who should fill out the Employee Accident Report form?
The form should be filled out by the employee who experienced the accident or injury. In cases where the employee is unable to complete the form due to their condition, a supervisor or designated representative may complete it on their behalf.
When should the form be completed?
The Employee Accident Report form should be completed as soon as possible after the incident occurs. Prompt reporting is essential to ensure that all details are fresh in the minds of those involved and to facilitate timely medical treatment if necessary.
What information is required on the form?
The form typically requires information such as:
- The date and time of the accident
- The location of the incident
- A description of what happened
- The names of any witnesses
- The nature and extent of the injuries
- Any immediate actions taken, such as first aid
Is the information on the form confidential?
Yes, the information provided on the Employee Accident Report form is considered confidential. It is used for internal purposes only, such as improving workplace safety and processing any necessary claims. However, certain details may be shared with relevant parties, such as insurance companies or legal representatives, as required by law.
What happens after the form is submitted?
Once the form is submitted, it will be reviewed by a supervisor or the HR department. They will assess the information provided and determine if further action is needed, such as an investigation into the incident or changes to workplace safety protocols.
Can the form be amended after submission?
If additional information becomes available after the form has been submitted, it may be possible to amend the report. Employees should communicate with their supervisor or HR department to ensure that any new details are documented appropriately.
What if I witness an accident but am not the one injured?
Witnesses to an accident should also report what they saw. They may be asked to provide a statement or fill out a separate report to ensure that all perspectives of the incident are captured. This information can be vital for understanding the circumstances surrounding the accident.
How does this form relate to workers' compensation?
The Employee Accident Report form is often a critical component of the workers' compensation process. Accurate and timely completion of this form helps establish the details of the injury, which can be necessary for filing a claim and receiving benefits.
Where can I obtain the Employee Accident Report form?
The form is typically available through your workplace's HR department or on the company’s internal website. Employees should ensure they have access to the most current version of the form to ensure compliance with any updated policies or procedures.

Form Overview

Fact Name	Description
Purpose	The Employee Accident Report form is used to document workplace accidents and injuries to ensure proper reporting and follow-up.
Who Completes It	Typically, the injured employee or a supervisor completes the form as soon as possible after the incident occurs.
Importance of Timeliness	Filing the report promptly helps in gathering accurate information and can affect workers' compensation claims.
Details Required	The form usually requires details such as the date, time, and location of the accident, as well as descriptions of the incident and injuries sustained.
State-Specific Variations	Some states have specific forms or additional requirements. For example, California mandates the use of the DWC-1 form for workers' compensation claims.
Confidentiality	The information collected is generally kept confidential and is only shared with authorized personnel for claims processing.
Legal Implications	Accurate completion of the form can protect both the employee's rights and the employer's interests in case of disputes.
Follow-Up Actions	After submission, employers are often required to take specific actions, such as investigating the incident and implementing safety measures.