Accident Report Form
01 WHAT IS AN ACCIDENT REPORT FORM?
All accidents are considered as incidents. However, an accident report form focuses more on
the injury whereas the incident report form is intended to focus on the cause and prevention of
further occurrences.
The Accident Report Form is in 2 parts. The first part is completed by the employee who
suffered the accident, and the second part is completed by the supervisor.
An accident report is an important tool used to document the accident and assist in investigating
the cause. It also assists to develop procedures that may be put in place to prevent it from
happening again.
The supplied template calls on the employee(s), with the assistance of a manager, to fill in the
first page details including:
✓ employee details
✓ injury details- including date, time and expected time off work
✓ medical treatment required
✓ events leading up to the injury- this is important to gain the employees perspective of what
actually happened.
02 SUPERVISOR’S REPORT
The second section of the form is to be completed by the manager and requires the manager to
identify the following:
✓ witness details
✓ how the accident happened
✓ how a recurrence can be prevented.
It is important to show outcomes of the investigation and to document what actions can or will
be taken to prevent another injury occurring in a similar scenario.
The Manager should decide whether or not the accident should also be documented as an
incident needing further investigation. This may well be the case depending on the cause of the
accident and the possibility of it happening again due to job design, system or procedural faults
needing additional investigation and control.
Should your company decide to merge both the accident and incident form together into one
document then the suitability of this should be assessed at senior management level to ensure
that a detailed and documented approach to both matters is still achieved.
NOTE: The template provided can be used for all accidents. However, it is important to
check with your state regulatory body requirements and/or your company Insurer about the
legal requirements for reporting “serious and notifiable incidents”.
Accident Investigation Report Form
EMPLOYEE DETAILS
Name: ____________________________ Position:_____________________________
Address: _______________________________________________________________
INJURY DETAILS
Date of accident: ___________ Time: ________ Date Reported: __________ Time: _________
Date ceased work: __________ Time: __________ Supervisor: __________________________
Time lost (to date): ___________________ Time lost (anticipated overall) __________________
Medical Treatment required:
______________________________________________________________________________
Nature and extent of injury
☐ Head ☐ Trunk ☐ Multiple
Part of body injured ☐ Eyes ☐ Arm ☐ General
☐ Neck ☐ Leg ☐ Unspecified
☐ Sprain ☐ Laceration ☐ Burn
Nature of injury ☐ Fracture ☐ Concussion ☐ Superficial
☐ Multiple ☐ Dislocation ☐ Amputation
☐ Contusion ☐ Other
☐ Flying ☐ Manual handling ☐ Electricity
object
Type of incident
☐ Struck by ☐ Poisons ☐ Fall
☐ Caught in ☐ Temperature ☐ Other
Describe the events leading up to the injury and how the injury occurred (witness or injured
person’s statement).
Accident Investigation - Supervisor’s Report
Witness Details
How did the accident happen?
What caused the ☐ Ineffective ☐ Lack of protective ☐ Lack of training
accidents guarding equipment
☐ Lack of ☐ Safety rules not ☐ Inexperience
maintenance followed
☐ Unsafe work ☐ Misconduct ☐ Workplace design
methods (equipment, design,
layout)
☐ Weather ☐ Poor ☐ Language
housekeeping difficulties
Explain
How can a recurrence be prevented?
Supervisor’s name: _______________________________________________________
Signature: _____________________________________ Date: ____________________
Appropriate Government/insurance bodies Advised? (If applicable) Yes/No
Date :_________________________
Is this a Work-related injury? Yes/No
Accident Investigation - Supervisor’s Report
Employer/Supervisor comments:
