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Fill Out a Valid Employee Accident Report Form

The Employee Accident Report form is a crucial document used to record details of workplace incidents that result in employee injuries or accidents. This form helps employers understand the circumstances surrounding the event, ensuring proper follow-up and compliance with safety regulations. For accurate documentation and to promote workplace safety, it is essential to fill out the form promptly by clicking the button below.

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Table of Contents

Form Overview

Fact Name	Description
Purpose	The Employee Accident Report form is used to document workplace accidents and injuries.
Who Completes It	Typically, the injured employee or a supervisor fills out the form.
Importance	This form is crucial for filing workers' compensation claims and ensuring workplace safety.
State Variations	Some states have specific forms or requirements, so it's essential to check local regulations.
Governing Laws	In many states, workers' compensation laws govern the use of the Employee Accident Report form.
Information Required	The form typically requires details like the date, time, location, and nature of the accident.
Submission Timeline	Most states require the form to be submitted within a specific timeframe after the accident.
Confidentiality	Information on the form is generally kept confidential and only shared with relevant parties.

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Documents used along the form

When an employee is involved in an accident at work, several forms and documents may be needed to ensure proper reporting and follow-up. Below are some key documents often used alongside the Employee Accident Report form.

Incident Investigation Report: This document outlines the details of the accident, including the circumstances, contributing factors, and any immediate actions taken. It helps in understanding what happened and how to prevent similar incidents in the future.
First Aid Report: If first aid was administered following the accident, this report details the treatment provided. It includes information about the injuries and the response of the first aid personnel, ensuring that all medical actions are documented.
Workers' Compensation Claim Form: This form is necessary if the employee seeks compensation for medical expenses or lost wages due to the accident. It collects information about the incident and the resulting injuries to support the claim process.
Return to Work Form: After an employee has recovered, this form is used to assess their readiness to return to work. It often requires a physician's approval and outlines any restrictions or accommodations needed for a safe return.
Safety Training Records: These documents track the safety training that employees have received. They can be useful in evaluating whether the employee had adequate training related to the incident and in identifying any gaps that need to be addressed.

Collectively, these documents play a crucial role in addressing workplace accidents. They ensure that incidents are thoroughly investigated and that employees receive the necessary support and follow-up care.

Document Sample

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		Age:

Department:	Job title at time of incident:

Part of body affected: (shade all that apply)	Nature of injury: (most	This employee works:
	serious one)	Regular full time
	Abrasion, scrapes	Regular part time
	Amputation	Seasonal
	Broken bone	Temporary
	Bruise	Months with
	Bruise
	Burn (heat)
	Burn (heat)	this employer
	Burn (chemical)	this employer
	Burn (chemical)
	Concussion (to the head)	Months doing
	Crushing Injury	this job:
	Cut, laceration, puncture
	Cut, laceration, puncture
	Hernia
	Illness
	Sprain, strain
	Damage to a body system:
	Other ___________

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
During meal period	During break	Working overtime Other___________________

Names of witnesses (if any):

Number of attachments:

Written witness statements:

Photographs:

Maps / drawings:

What personal protective equipment was being used (if any)?

Describe, step-by-step the events that led up to the injury. Include names of any machines, parts, objects, tools, materials and other important details.

	Description continued on attached sheets:


Step 3: Why did the incident happen?
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: __________________________________

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

Have there been similar incidents or near misses prior to this one?	Yes	No

Step 4: How can future incidents be prevented?

What changes do you suggest to prevent this incident/near miss from happening again?

	Stop this activity	Guard the hazard	Train the employee(s)	Train the supervisor(s)
	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:

Names of investigation team members:

Reviewed by:

Title:

Date: