Accident/incident Report Form (Page 2 of 2) in pdf

Accident/Incident Report Form

page 2

SECTION III

SUPERVISOR REPORT ON THE ACCIDENT/INCIDENT

What action has been taken to prevent such an accident/incident from recurring? Include specific details on how it was

mediated, how the incident can be avoided in the future. (Note that photos are highly recommended immediately following an

incident, if at all possible.)

_____________________________________________________________________________________________________________

Supervisor’s Account of Incident which supplements and/or clarifies information provided by injured party:

(if an injury, (1) explain

activities occurring when injury or illness occurred and what tools, machinery, chemicals, were involved, (2) what happened to cause this injury or illness (3) what was

the injury or illness (i.e., state the part of body affected and how it was affected)

_____________________________________________________________________________________________________________

Section III Completed by: ____________________________________________

___________________

Signature

Date

SECTION IV- FOR INVESTIGATION/REVIEW ONLY - DO NOT WRITE BELOW THIS LINE:

Investigation Comments: Photos are highly recommended immediately following an incident, if at all possible.

Required Action:

Location Code: ____

Section IV Completed by: ____________________________________________

___________________

Signature

Date

Date sent to supervisor: ________________

other ___________________________

7/11/12

Accident-Incident Report

Accident/incident Report Form Page 2

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