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Employee Accident Report Form Template

Streamline Workplace Incident Reporting with Our Template

When accidents happen at work, timely reporting is crucial for safety and compliance. This Employee Accident Report Form Template helps you efficiently capture essential details surrounding workplace incidents, ensuring accurate documentation. You can track the date and time of the accident, record locations, gather descriptions, and list witnesses-all while collecting your employees' contact information in one easy form. Whether you're looking to enhance safety protocols, streamline incident reporting, or comply with regulations, this template supports your needs. Try out the live template to see how it works for you.

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Reporter full name
Reporter email
Report date
Who is completing this report?
Injured employee
Supervisor or manager
Coworker
Safety representative
HR representative
Other
Please Specify:
Is the injured person the same as the reporter?
Yes
No
Injured employee full name
Job title
Employment relationship
Employee
Temporary or agency worker
Contractor
Visitor
Volunteer
Prefer not to say
Other
Please Specify:
Date of incident
Time of incident (local time, e.g., 14:30)
Location type
On company premises
Client site
Off-site while on work duty
Remote or telework location
During commute
Unknown
Other
Please Specify:
Specific location or address
Work being performed at the time
Incident type
Please Specify:
Describe what happened (facts only)
Contributing factors (select all that apply)
Please Specify:
Was anyone injured?
Yes
No
Nature of injury or illness (select all that apply)
Please Specify:
Body part(s) affected (select all that apply)
Please Specify:
Initial severity assessment
No apparent injury
First aid only
Medical treatment beyond first aid
Restricted duty
Lost time
Fatality
Unknown
Was first aid provided on site?
Yes
No
Not applicable
Time lost from work
No time lost
Left early same day
Missed next shift
Multiple days off
Unknown
Witness name
Witness contact (phone or email)
Were there any witnesses?
Yes
No
Unknown
Date supervisor was notified
Immediate actions taken or recommended
Has a supervisor been notified?
Yes
No
Signature (type your full name)
Signature date
I certify that the information provided is accurate to the best of my knowledge.
Yes
No
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paper art illustration depicting an employee accident report form with details and fields for information

When to use this form

Use this form right after any work-related injury, exposure, or near miss involving an employee. Examples include a slip on a wet floor, a hand cut from a tool, a chemical splash, or a forklift bump in the warehouse. You, your supervisor, safety, HR, and insurance partners benefit from one accurate record. It captures facts fast, supports medical care, and helps identify root causes and corrective actions. For incidents that do not involve employees or are purely property damage, route them to the General incident report form. Construction teams with jobsite injuries should use the Construction accident report form. If you need a broader, non-role specific layout for mixed audiences, start with the Accident report form.

Must Ask Employee Accident Report Questions

  1. What was the date and exact time of the incident?

    A precise timestamp lets you match the event to shift rosters, equipment logs, and video footage. It also clarifies reporting deadlines and helps reconstruct environmental conditions.

  2. Where did the incident occur (site, department, and specific area)?

    Location details reveal hazard hotspots and help you prioritize fixes. Naming the exact area speeds isolation, signage, and notifications to the right supervisors.

  3. What task was the employee performing, and what exactly happened?

    Task context connects the sequence of events to procedures, training, and potential unsafe conditions. A clear narrative supports root-cause analysis and targeted prevention.

  4. What injuries were sustained, and which body parts were affected?

    This guides first aid and medical care and establishes severity. Accurate injury data supports OSHA recordability decisions and workers compensation claims.

  5. What immediate actions were taken, who was notified, and were there witnesses?

    Documenting response actions and notifications shows control of the hazard and legal compliance. Witness names and contact details allow timely follow-up and preserve evidence quality.

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