Accident Incident and Witness Statement

Date of Incident:*
Location of Incident:*
Supervisor:*
Was there an injury involved with this incident?:*
Please specify if any of the following were administered:
Hold down the Control button and Click to select multiples
Who was hurt?:
- Employee
- Visitor
- Contractor
- Other
What is your role in this incident?:*
Please upload any images or additional documentation you would like to include:
Drop files here or

Accepted file types: jpg, jpeg, png, pdf, docx, doc, Max. file size: 100 MB.
Acceptable File Formats: .jpg, .jpeg, .png, .pdf, .docx, .doc
This section to be completed by the employee
First Name:*
Last Name:*
Phone Number or Extension:*
Job Title:*
Department:*
Time of Incident:*

: Hours

Minutes

AM/PM
Date Reported:*
Employees Description of Alleged Accident / Incident:*
Type of Incident:*
Hold down the Control button and Click to select multiples
Please Describe:*
If this was a SLIP, describe footwear:*
Witnesses To The Incident:*
Name: Phone Number:
What was the injury?*

Please indicate what part of the body?:
Did you seek or witness any medical treatment?*
If YES, please provide the following:*
Name Address Phone Number
Treatment of Injury:*
Please Describe:*
Consent*
By clicking this box I consent to enter this as an official company record
Please Enter Your Full Name:*
Date:*
MM slash DD slash YYYY
This Section To Be Completed By The Supervisor
Contributing Factors:*
Hold down the Control button and Click to select multiples
Please Explain*
Explanation of contributing factors:*
Details of property damage:*
Details of property damage:*
To your knowledge, has the employee had a previous similar injury or has this similar hazard been reported before?*
- Yes
- No
- N/A
Corrective Measures:*
Actions taken to prevent a reoccurrence (more than one item may apply). Hold down the Control button and Click to select multiples
Explanation of Corrective Measures:*
Consent*
By clicking this box I consent to enter this as an official company record
Please Enter Your Full Name:*
Date:*
MM slash DD slash YYYY
Witness Statement
Witness's Name:
Date
MM slash DD slash YYYY
(PLEASE PRINT STATEMENT OF ACCIDENT/INJURY BELOW)
Injured Employee's Name:
Witness Signature:

(Typed Name as Signature Affirming Events)
Date
MM slash DD slash YYYY
Phone
This field is for validation purposes and should be left unchanged.

Name:	Phone Number:

Name	Address	Phone Number

Accident Incident and Witness Statement

This section to be completed by the employee

This Section To Be Completed By The Supervisor

Witness Statement