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Accident Incident and Witness Statement
Accident Incident and Witness Statement
Date of Incident
*
Location of Incident
*
Supervisor
*
Was there an injury involved with this incident?
*
Injury
No injury
Hazardous Situation
What is your role in this incident?
*
Employee
Supervisor
Witness
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Please fill out the form below if you are an EMPLOYEE
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Name
Name
First
First
Last
Last
Phone Number or Extension
Job Title
Department
Time of Incident
12
1
2
3
4
5
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7
8
9
10
11
:
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30
AM
PM
Date Reported
Employees Description of Alleged Accident / Incident
Type of Incident
Sli, Trip, or Fall
Struck by / Against object
Over Extertion
Repetitive Strain
Electrical Contact
Exposure to Hazardous Material/Substances
Company Property Damage
Contractor’s Property Damage
Other
Please Describe
Witness to the Accident
Witness to the Accident
First
First
Last
Last
What was the injury?
Did you seek or witness any medical treatment?
Yes
No
If YES, please provide the following
If YES, please provide the following
First
First
Last
Last
Address
Phone
Treatment of Injury
Please Specify
First Aid
Walk-in Clinic
Family Doctor
Emergeny Room
Other
If OTHER, please describe
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I consent
Signature
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Date Submitted
Please fill out the form below if you are a SUPERVISOR
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Contributing Factors
Please Specify
Inadequite Illumination
Unsafe Equipment
Not Properly Guarded
Hazardous Environment
Insufficient Care
Improper Position or Posture
Infraction or Unsafe Practice
Failure to use PPE
Operating without PPE
Operating without Authority
Failure to Lock Out
Other
If OTHER, please specify
Explanation of Contributing Factors
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
Please Specify
Request Job Safety Analysis
On-The-Job Training
Perform House Keeping
Review PPE
Improve Work Procedure
Check With Manufacturer
Retraining of Person(s)
Constructive Discipline
Repair or Replace Equipment
Install Safety Guard/Device
Reassignment of Person
Other
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I consent
Signature
signature
keyboard
Clear
Date Submitted
Please fill out the form below if you are a WITNESS
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Witness Name
Witness Name
First
First
Last
Last
Date
(PLEASE PRINT STATEMENT OF ACCIDENT/INJURY BELOW)
Injured Employee’s Name
Injured Employee's Name
First
First
Last
Last
Witness Signature
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Date Submitted
Submit
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