The Employee Accident Report form is a crucial document used by organizations to record details of workplace incidents involving employees. This form helps ensure that all relevant information is collected and documented accurately, facilitating investigations and improving workplace safety. Understanding how to properly complete this form is essential for both employees and employers alike.
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
Burn (heat)
this employer
Burn (chemical)
Concussion (to the head)
Months doing
Crushing Injury
this job:
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):
1
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?
2
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?
Step 5: Who completed and reviewed this form? (Please Print)
Written by:
Title:
Date:
Names of investigation team members:
Reviewed by:
3
Understanding the Employee Accident Report form is crucial for both employees and employers. Unfortunately, there are several misconceptions that can lead to confusion. Here’s a list of ten common misunderstandings about this important document:
By clearing up these misconceptions, employees can better navigate the process and contribute to a safer workplace for everyone.
Filling out an Employee Accident Report form is an important process that helps ensure workplace safety and proper documentation of incidents. Here are some key takeaways to keep in mind:
Understanding these key points can help streamline the reporting process and contribute to a safer workplace environment.
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