The Employee Accident Report form is a crucial document used to record details of workplace incidents involving employees. This form helps ensure that all necessary information is captured for proper investigation and resolution. To contribute to a safer workplace, please fill out the form by clicking the button below.
This is incorrect. Any workplace accident, regardless of severity, should be reported to ensure proper documentation and follow-up.
While the injured party should provide their account, witnesses or supervisors can also complete the form to provide additional context.
Reporting an accident is a safety measure, not a punitive action. The goal is to improve workplace safety, not to assign blame.
While prompt reporting is encouraged, it’s important to ensure that all information is accurate. Take the necessary time to gather details.
The report serves multiple purposes, including identifying safety hazards and preventing future incidents, not just for insurance claims.
While personal information is protected, the details may be shared with relevant parties to address safety concerns and improve procedures.
Accurate reporting can lead to significant improvements in workplace safety, ultimately benefiting everyone in the organization.
Accidents that result in near misses or property damage should also be reported to help identify and mitigate risks.
When an employee experiences an accident at work, several forms and documents may be necessary to ensure proper reporting, investigation, and follow-up. Each document serves a specific purpose in documenting the incident and supporting the employee's needs. Below is a list of commonly used forms alongside the Employee Accident Report form.
These documents work together to create a comprehensive picture of the accident, ensuring that all necessary steps are taken for the employee's well-being and the safety of the workplace. Proper documentation not only aids in the recovery process but also helps prevent future incidents.
Filling out an Employee Accident Report form can be a straightforward task, but many people make mistakes that can complicate the process. One common error is failing to provide complete information. When details are missing, it can lead to confusion and delays in processing the report.
Another mistake is not reporting the accident in a timely manner. Delays can hinder the investigation and might even affect the employee's ability to receive benefits. It’s crucial to report the incident as soon as possible to ensure that all necessary information is captured.
Some individuals forget to include witnesses. If there were others present during the accident, their accounts can provide valuable context. Not listing witnesses may result in a lack of corroborating evidence, which can weaken the report.
Inaccurate descriptions of the incident are also a frequent issue. People may omit important details or exaggerate certain aspects. It is essential to stick to the facts and provide a clear, honest account of what happened.
Another common error is neglecting to mention any prior injuries or conditions. This information can be relevant and might affect the outcome of the report. Transparency is key, so it’s important to disclose any relevant medical history.
Some individuals fail to follow the proper format or guidelines for filling out the form. Each organization may have specific requirements, and not adhering to these can lead to complications. Always check to ensure that the form is filled out correctly.
Additionally, not signing the report is a critical mistake. A signature indicates that the information provided is accurate and complete. Without a signature, the report may be deemed invalid.
Finally, many people overlook the importance of keeping a copy of the completed report. Having a personal record can be beneficial for future reference or if any disputes arise. Always retain a copy for your files.
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
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