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Fill in a Valid Employee Accident Report Form

The Employee Accident Report form is a crucial document used to record details of any workplace accidents. It helps ensure that all incidents are documented accurately for safety reviews and potential claims. Understanding how to complete this form properly can help protect both employees and employers in the event of an accident.

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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:

Document Information

Fact Name	Description
Purpose	The Employee Accident Report form is used to document workplace accidents, ensuring that incidents are recorded for safety and legal compliance.
Who Completes It	The report is typically completed by the injured employee or a supervisor who witnesses the accident.
Information Required	Details such as the date, time, location of the accident, and a description of the incident are required to provide a comprehensive overview.
State-Specific Variations	Some states may have specific versions of the form that align with local laws and regulations regarding workplace safety.
Governing Laws	In California, for example, the form must comply with the California Labor Code Section 6409, which mandates the reporting of workplace injuries.
Submission Process	Once completed, the form is typically submitted to the employer’s human resources department or designated safety officer.
Confidentiality	Information contained within the report is generally kept confidential to protect the privacy of the injured employee.
Importance of Timeliness	Submitting the report promptly is crucial, as delays may affect workers' compensation claims and the employer's liability.

Employee Accident Report - Usage Guidelines

Completing the Employee Accident Report form is an important step in documenting workplace incidents. Following the correct procedure ensures that all necessary information is captured accurately. Here are the steps to fill out the form effectively.

Begin by entering the date of the accident in the designated field.
Provide your full name as the employee involved in the incident.
Fill in your job title and department to clarify your role within the organization.
Indicate the location where the accident occurred, including specific details if applicable.
Describe the nature of the accident. Be clear and concise about what happened.
List any witnesses to the incident, including their names and contact information.
Detail any injuries sustained, including the body parts affected.
Document any immediate actions taken following the accident, such as first aid or reporting to a supervisor.
Sign and date the form to certify that the information provided is accurate.

Once the form is completed, submit it to your supervisor or the designated safety officer. This will initiate the review process and ensure that appropriate actions are taken following the incident.

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Dos and Don'ts

When filling out the Employee Accident Report form, clarity and accuracy are essential. Here’s a list of things to do and avoid to ensure the process goes smoothly.

Do provide a detailed account of the incident, including what happened, where it occurred, and when.
Do include the names and contact information of any witnesses.
Do describe any injuries sustained, even if they seem minor.
Do use clear and straightforward language to avoid confusion.
Do sign and date the report to validate the information provided.

Don't leave out important details, as this could lead to misunderstandings.
Don't use vague terms; be specific about the events that transpired.
Don't alter or erase any information once it has been written down.
Don't forget to submit the report promptly to ensure timely processing.
Don't discuss the incident with others before submitting the report, as it may complicate matters.

Following these guidelines can help ensure that the Employee Accident Report is completed accurately and effectively, paving the way for appropriate follow-up actions.

Common mistakes

Incomplete Information: Many individuals fail to provide all required details, such as their name, job title, and department. This omission can lead to delays in processing the report.
Vague Descriptions: Some reports contain unclear or ambiguous descriptions of the accident. Specificity is crucial for understanding the circumstances surrounding the incident.
Missing Witness Statements: Witnesses can provide valuable insights. Neglecting to include their statements can weaken the report’s credibility.
Failure to Document Injuries: Not detailing the injuries sustained during the accident can hinder the assessment of the situation and the necessary follow-up actions.
Ignoring Safety Protocols: Some individuals overlook mentioning whether safety protocols were followed. This information is essential for evaluating workplace safety measures.
Inaccurate Dates or Times: Errors in recording the date or time of the incident can complicate investigations and lead to misunderstandings.
Not Reporting Near Misses: Failing to report near misses can prevent organizations from addressing potential hazards before they lead to actual accidents.
Neglecting Follow-Up Actions: Some forms lack information on any immediate actions taken after the accident, such as first aid or notifying a supervisor.
Submitting Late Reports: Timeliness is crucial. Delayed submissions can affect investigations and the ability to implement corrective measures effectively.

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