Download Employee Accident Report Form in PDF

The Employee Accident Report form is a crucial document used by organizations to record details of workplace accidents involving employees. This form captures essential information about the incident, including the nature of the accident, the individuals involved, and any witnesses present. Proper completion of this report not only aids in understanding the circumstances surrounding the event but also plays a vital role in improving workplace safety protocols.

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Download Employee Accident Report Form in PDF

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When an employee is involved in an accident at work, documenting the incident is crucial for both the employee and the employer. The Employee Accident Report form serves as a vital tool in this process. It captures essential details such as the date, time, and location of the accident, as well as a description of the events leading up to the incident. The form also includes sections for the names and contact information of witnesses, which can provide valuable insights into what happened. Additionally, it allows for the reporting of any injuries sustained, ensuring that the employee receives appropriate medical attention and support. By filling out this form, employees can help their employers understand the circumstances surrounding the accident, leading to better safety measures and policies in the workplace. Properly completed, this form not only aids in compliance with workplace safety regulations but also serves as a record for potential insurance claims or legal matters that may arise from the incident.

Document Data

Fact Name	Description
Purpose	The Employee Accident Report form is used to document workplace accidents and injuries. It helps employers track incidents and ensures proper reporting for insurance and safety compliance.
Who Completes It	The form is typically completed by the employee involved in the accident or a supervisor who witnesses the event. Accurate information is crucial for effective follow-up.
State-Specific Laws	Each state may have specific laws governing the reporting of workplace accidents. For example, in California, employers must comply with Cal/OSHA regulations, which require detailed reporting of workplace injuries.
Importance of Timeliness	Filing the report promptly is essential. Many states have deadlines for reporting workplace injuries to ensure compliance with workers' compensation laws.

How to Write Employee Accident Report

Completing the Employee Accident Report form is a crucial step in documenting any workplace incident. This report helps ensure that all relevant information is collected and can facilitate necessary follow-up actions. Follow these steps carefully to fill out the form accurately.

Begin by entering your personal information, including your name, job title, and department.
Provide the date and time of the accident. Be as precise as possible.
Describe the location where the accident occurred. Include specific details to help identify the site.
Detail the nature of the accident. Clearly explain what happened, including any equipment or materials involved.
List any witnesses to the incident. Include their names and contact information if available.
Indicate any injuries sustained. Be specific about the type and severity of the injuries.
Sign and date the report to confirm that the information provided is accurate.

After completing the form, submit it to your supervisor or the designated safety officer. Timely submission is essential for ensuring that appropriate actions are taken following the incident.

Employee Accident Report Example

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:

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