Employee Incident/Accident Reporting Form

I am completing this form as the:

I am reporting an:

Supervisor's Information

Name

Phone number

Injured/Ill Individual's Information

Name

Phone number

Department

Employment Status

Job Title

Employment Start Date

Is this an incident notice only?

Accident/Illness Information

Date of Accident or Illness

Time of Accident

Location where Accident Occurred

Was the employee conducting Institute business at the time of injury?

If not conducting institute business, please explain.

What was the employee doing when the injury/illness occurred? What machine or tool was being used? What type of operation?

How did the injury/illness occur? List all objects and substances involved.

List any witnesses

Hazard

Other hazard

Describe the hazard that applies that is not listed above

Injury Classification

Other injury description

Outcome

Was first aid administered at time of incident?

What type of first aid was administered?

Property/Equipment Damaged

Part of body affected/injured?

Nature and extent of injury/illnesses and property damage (be specific)

List any prior physical injuries

Did the employee receive prescription medication?

Additional Questions

Please indicate all of the following which contributed to the injury/illness:

Specify other items which contributed to the injury/illness:

Supervisor's corrective action to ensure this type of accident does not recur:

Was the employee cautioned for failure to use Personal Protective Equipment/proper safety procedures?

Was the employee trained in the appropriate use of Personal Protective Equipment/proper safety procedures?

Did the employee promptly report the injury/illness?

If not reported within 24 hours, please explain.