Date of report:

Time:

Employee involved:

Age:

Position:

Date of employment:

Supervisor:

Department:

Date of accident:

Time of accident:

Date accident reported:

Did the accident result in injury?

Length of time employee performed operation:

Was the employee instructed?

Location of injury:

Nature and extent of injury:

Was first aid given?

If so, when and by whom?

How did accident occur?

Cause of accident:

Recommendations to prevent a recurrence:

What action has been taken?

Names of witnesses who saw the accident:

1)

2)

3)

4)

5)

Names of people who have knowledge of the accident or injury:

1)

2)

3)

4)

5)

Employee signature:

Date:

Supervisor’s signature:

Date: