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The Employee Accident Report form serves as a crucial tool in workplace safety and compliance. It enables employees to document incidents that result in injuries or near misses, ensuring that all relevant details are captured promptly and accurately. Typically, the form includes sections for personal information, a description of the incident, witnesses, and the nature of the injuries sustained. Additionally, it often requires information about the circumstances leading to the accident, such as the location and any equipment involved. By standardizing the reporting process, this form not only aids in the immediate response to workplace accidents but also contributes to long-term safety improvements and risk management strategies. Organizations can analyze the collected data to identify patterns, implement preventive measures, and ultimately foster a safer work environment for all employees.
Employee Accident Report Preview
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 |
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Age: |
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Department: |
Job title at time of incident: |
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Part of body affected: (shade all that apply) |
Nature of injury: (most |
This employee works: |
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serious one) |
Regular full time |
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Abrasion, scrapes |
Regular part time |
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Amputation |
Seasonal |
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Broken bone |
Temporary |
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Bruise |
Months with |
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Burn (heat) |
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this employer |
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Burn (chemical) |
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Concussion (to the head) |
Months doing |
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Crushing Injury |
this job: |
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Cut, laceration, puncture |
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Hernia |
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Illness |
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Sprain, strain |
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Damage to a body system: |
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Other ___________ |
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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 |
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During meal period |
During break |
Working overtime Other___________________ |
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Names of witnesses (if any):
1
Number of attachments:
Written witness statements:
Photographs:
Maps / drawings:
What personal protective equipment was being used (if any)?
Describe,
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Description continued on attached sheets: |
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Step 3: Why did the incident happen? |
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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: __________________________________ |
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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 |
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Have there been similar incidents or near misses prior to this one? |
Yes |
No |
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Step 4: How can future incidents be prevented?
What changes do you suggest to prevent this incident/near miss from happening again?
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Stop this activity |
Guard the hazard |
Train the employee(s) |
Train the supervisor(s) |
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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: |
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Names of investigation team members: |
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Reviewed by:
Title:
Date:
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Common mistakes
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Inadequate Details: Many individuals fail to provide enough specifics about the accident. This includes not mentioning the exact time, location, and circumstances that led to the incident.
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Omitting Witness Information: Some reports lack the names and contact information of witnesses. This can hinder the investigation process and limit corroborating evidence.
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Incorrect Dates: Filling in the wrong date of the incident is a common mistake. This can create confusion and complicate the timeline of events.
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Failure to Describe Injuries: Not detailing the nature and extent of injuries can lead to misunderstandings regarding the severity of the accident.
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Neglecting to Sign: Some individuals forget to sign the report. An unsigned document may be considered incomplete and may not be taken seriously.
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Using Vague Language: Phrases like “I slipped” without explaining how or why can lead to ambiguity. Clear, descriptive language is crucial.
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Not Reporting Near Misses: Failing to report near misses can prevent future accidents. Each incident, even if no injury occurs, is valuable for safety improvements.
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Ignoring Company Policies: Some employees do not follow the specific guidelines set by their employer for completing the form. This can result in incomplete or improperly submitted reports.
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Dos and Don'ts
When filling out the Employee Accident Report form, accuracy and attention to detail are crucial. Here are some important dos and don'ts to keep in mind:
- Do provide a clear and detailed description of the accident.
- Do include the date, time, and location of the incident.
- Do list any witnesses and their contact information.
- Do sign and date the report to validate your submission.
- Do keep a copy of the completed form for your records.
- Don't leave out any important details, as this can lead to misunderstandings.
- Don't use vague language; be as specific as possible.
- Don't assign blame or make assumptions about the cause of the accident.
- Don't ignore the reporting deadlines set by your employer.
- Don't forget to review the form for errors before submission.
Misconceptions
Many people misunderstand the purpose and function of the Employee Accident Report form. Here are eight common misconceptions:
- It’s only for serious accidents. Some believe that the form is only necessary for major injuries. In reality, it should be completed for any incident, regardless of severity, to ensure proper documentation and follow-up.
- Only management can fill it out. This is not true. Employees involved in the accident should complete the form. Their perspective is crucial for an accurate report.
- Filling it out is optional. Some think that submitting the report is optional. However, it is typically required by company policy and may also be mandated by law.
- It’s only needed for workers' compensation claims. While it can support a claim, the report serves multiple purposes, including improving workplace safety and identifying patterns in incidents.
- It’s a blame tool. Many fear that the form is used to assign blame. Instead, it aims to gather facts and enhance safety measures, not to penalize individuals.
- It should be filled out immediately. While prompt reporting is encouraged, it’s more important that the report is thorough and accurate. Taking time to gather all necessary details is beneficial.
- Confidentiality is not a concern. Some assume that their information will be shared widely. In fact, these reports are usually treated confidentially to protect the privacy of those involved.
- It’s only for workplace accidents. People often think it applies solely to accidents occurring on the job. However, it can also cover incidents that happen during work-related activities off-site.
Understanding these misconceptions can lead to better reporting practices and a safer workplace for everyone.
Detailed Guide for Using Employee Accident Report
After you receive the Employee Accident Report form, it's essential to complete it accurately and promptly. This report will be used to document the details of the accident and initiate the necessary follow-up actions. Follow these steps to ensure the form is filled out correctly.
- Begin by entering the date and time of the accident in the designated fields.
- Provide the location where the accident occurred. Be specific to help with any follow-up investigations.
- Fill in your name and contact information. Include your job title and department.
- Describe the accident in detail. Include what happened, how it happened, and any equipment involved.
- List any witnesses to the accident. Include their names and contact information if available.
- Document any injuries sustained. Be clear about the nature and extent of the injuries.
- Sign and date the form to confirm the information is accurate.
- Submit the completed form to your supervisor or the designated safety officer as soon as possible.