Accident Report
Facility Info
Facility
Operations Manager
Incident Type
Near Miss
Recordable
First Aid
Reportable
Employee Name
Logged in as:
Employee ID
Address 1
Address 2
City
State
Zip
Department
Employee Category
Job Code
Job Start Date
Gender
Female
Male
Date Of Birth
Employee Notes
Incident
Incident Date / Time
Date / Time of Employers Knowledge
Time Started Work
Time Ended Work
Reason For Accident
Severity
Recurrence Probability
Stopped Working
Yes
No
Date
Resumed Work
Yes
No
Date
Reported By
Treatment Provided By
Internal
Hospital / Doctor
Company Doctor Aid
Who Noticed Injury
Also an Eye Witness?
Yes
No
Agency Worker
Yes
No
Is Trainee
Yes
No
Injured Body Parts
Type of Injury
Fatality
Yes
No
Affiliation
Employee
Employer
Spouse of Employer
Related to Employer
Director
Claim of Continued Pay
Days Away From Work
Days on Job Transfer
Corrective Action URL
Corrective Action
Corrective Action Assessment
Corrective Action Status
Completed
Immidiate Action Completed
N\A
Further Detail of Injured Body Part
Type of First Aid given
If First Aid refused, sign and date here:
I hereby certify that the above statements are true and correct to the best of my knowledge:
Signature:
Date:
Witness Statement:
Follow Up Statements: