Accident Investigation Report v 1.

0
Effective Date: Date for Review:
Employee Form
August 15, 2023 August 15, 2024

INSTRUCTIONS

Employees shall use this form to report all work-related injuries, illnesses, or “near miss”
events (which could have caused an injury or illness)–no matter how minor. This helps us to
identify and correct hazards before they cause serious injuries. This form shall be completed
by employees as soon as possible and given to a supervisor for further action.

EMPLOYEE INFORMATION

Name:

Job Title:

Supervisor:

INCIDENT DETAILS

Date: Time:

Location:

Type of Report: ☐ Injury   ☐ Illness   ☐ Near Miss

Has your supervisor been informed of the incident? ☐ Yes   ☐ No  

Witnesses (if any):

What were you doing at the time?

Describe step-by-step what led up to the incident. (Continue on the back if needed):

SOP: Sample Title of the Procedure v 1.0 Page 1 of 2

 Accident Investigation Report v 1.0
Effective Date: Date for Review:
Employee Form
August 15, 2023 August 15, 2024

What could have been done to prevent this incident?

What parts of your body were injured? If a near miss, how could you have been hurt?

MEDICAL ATTENTION

Did you see a doctor about this incident? ☐ Yes, see below   ☐ No  
Date: Time:

Treating Physician:

Phone Number:

Has this part of your body been injured before? ☐ Yes, date: ☐ No  

Employee’s Signature Over Printed Name Date

SOP: Sample Title of the Procedure v 1.0 Page 2 of 2