Accident report form

download accident report template

This form is designed for the purpose of reporting an accident that might injure workers at the workplace. The organization is highly committed to administer health and safety guidelines for all the workers and expects them to abide by them to avoid any such instances. The organization is aware of the fact that accidents and injuries are inevitable. Therefore, the aim of this document is to ensure that any kind of such incident is timely reported so that the case can be investigated properly. The form will also be helpful to the organization to review and reinforce the preventive measures in future.

Accident report form - download template
*These templates are provided AS IS. They may not be any good. Even if they are good in one state, they may not be accurate in another.Templates are for informational purposes only - you should consult an lawyer before using them.

Download Accident Report Template*

*These templates are provided AS IS. They may not be any good. Even if they are good in one state, they may not be accurate in another.Templates are for informational purposes only - you should consult an lawyer before using them.

Important Guidelines for Filling the Form

The document contains important guidelines of reporting the accident, proceedings after the accident, and accidents that can be reported using this form.

The accident report should contain detailed information about the incident and a description of the losses and damages suffered by the victim (worker). To justify the damages or injuries, the applicant or the person reporting the case should enclose medical documentation with the report. It will also be good to enter the details of witnesses of the incident (if any).

The accident report form should be filled on the same day by the victim if the health condition is stable enough to report the case by themselves. In case, the victim is not able to notify or report the incident, the immediate supervisor/manager should do it. The witnesses of the case are also obliged to report to the concerned supervisor/manager about the accident as soon as possible.

The organization encourages workers to report any kind of accidents whether major or minor except small cuts and bruises that may not require extensive treatments. However, incidents with sever nature requiring thorough investigation and treatment should be reported dutifully. Workers can report the following accidents using the form:

  • Fatalities
  • Damage to the body such as the skull, head, or face
  • Dislocation of limbs or organ breakdowns that hinder movements
  • Damage to senses
  • Loss of consciousness or nervous breakdown
  • Poisoning
  • Blows or injuries to the body
  • Any other injury requiring immediate health care and hospitalization

Documents Needed for Reporting

The report must contain the given documents so that the organization can investigate the incident effectively and provide the required remedial support.

  • Description of the incident (provided directly by the victim or the immediate supervisor)
  • Personal details of witnesses
  • Copy of victim’s (worker) identity and workplace card
  • Medical documentation from the hospital
  • Medical diagnosis
  • Other important and related information

Procedure for Filling the Report Form

The section requires the victim or the immediate supervisor/manager to fill the form on the same day of the occurrence of the incident.

  1. The filler should have attached necessary documents such as identification details of the victim, date, and time of the accident.
  2. Attaching the description of incident supported by at least two witnesses.
  3. Details of witnesses (at least two) to be attached.
  4. Immediate medical documents or medical prescriptions.
  5. Any other important information relating to the case is encouraged to be provided with relevant documents.

Guidelines for the Submission of the Accident Report Form

The report filer (victim or the supervisor filling on victim’s behalf) must submit the report form to the employer on the same day of the incident or within three days of the incident (in case of a highly turbulent situation). The report can be submitted to the health and safety compliance department at the head office through a formal email or in hand by the report filer. The report can also be submitted through courier if the event has occurred at any plant or other than the head office location.

Mistakes to be Avoided While Filling and Submitting the Report

Following are the common mistakes that should be avoided by the filers while filling and submitting the accident report form:

  • Not quoting or mentioning the details of the incident
  • Quoting irrelevant details that are not directly related to the event
  • Omitting to mention the losses or injuries suffered
  • Missing medical and other relevant documents
  • Filling and submitting the form without witnesses
  • Submitting incomplete forms
  • Submitting the forms with delays
  • Submitting the form to other departments such as finance or administration

The form filer must be mindful that they provide correct and relevant information while filling the form so that the organization can take appropriate actions to avoid such occurrences in the future.

Important Points to Note

  1. The actual incident and its causes
  2. The victim and injuries suffered
  3. Identification of witnesses and filer (in case the victim is not able to fill the form)
  4. Completing the form within the given time and submitting with required documents to the relevant department.

Steps to Complete the Accident Report Form

Entering

the data of victim and the losses suffered

Describing

the event and its causes thoroughly

Entering

the details of witnesses

Attaching

relevant and important documents to support the case

Avg rate: 5.00

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