Sample Accident Report Form

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Part 1:  Complete For All Accidents

Date: Time:
Location:

Description of the accident: (Be specific)

Witness name and address:

Daytime phone number:
Witness name and address:

Daytime phone number:
Factors involved: (Check one or both and specify what acts or conditions)
( ) Unsafe act:

( ) Unsafe condition:

What corrective action was taken, if any?
Supervisor's signature: Date:

Part 2 - Complete For Each Injured Person:

Name of injured person:

 

Address, city, state and zip code:
Phone Numbers:
Work phone:

Home phone:
Gender:  ( ) Male    ( ) Female

Age:

Nature of injury:

 

Affected body part(s):
Status of the injured person:
( ) Staff member
( ) Client
( ) Visitor
( ) Other (specify): __________________
Cause of the injury: (Check all that apply and specify)
( ) An object:
( ) Equipment or tool:
( ) Hazardous substance:
( ) Other:
Severity of the injury:
( ) Minor (First aid)
( ) Severe, but not disabling
( ) Severe and disabling
( ) Fatality
Protective equipment:
( ) Was required
( ) Was available
( ) Was used
( ) Was not sufficient to prevent injury
Medical treatment provided by:

Comments:

Part 3 - Complete For Employees:

Job title:

 

Status:  (  ) Full-time      ( ) Part-time
Injured while on the job:
(
  )
Yes   ( ) No

Job being perfumed when injury occurred:
Stopped work immediately:
(
  ) Yes   ( ) No

 

Date supervisor learned of injury:

Person Completing This Form:

Name:

Date:
Job title:

Phone number:

 




Nonprofit Risk Management Center

15 N. King Street, Suite 203, Leesburg, VA 20176
Phone: (202) 785-3891 - Fax: (703) 443-1990

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This document is from the Nonprofit Risk Management Centerís
Accident Preparation and Response Tutorial (www.nonprofitrisk.org), which was
made possible by financial support from the Public Entity Risk Institute.