Accident Report
Instructions for completing the form.
Date of Accident
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Time of Accident
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Severity:
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Disclaimer
You understand that by selecting the severity noted with (A), an alert will be sent to inform the appropriate parties that an accident has occurred.
Person(s) Involved List
| First Name | Last Name | Phone | ||
|---|---|---|---|---|
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Person(s) Involved
Affiliation
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Gender
Activity at the time of accident?
Condition at the time of accident?
Equipment used
Suspected Nature of Injury
Suspected Body Part Injured
Tap the injured body area on the diagram
No Injury Added
Suspected Injury List
| Type of Injury | Body Part Injury | Action Taken | |
|---|---|---|---|
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Add Injury
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Refused Care Statement
Self Care Statement
Emergency Personnel List
| First Name | Last Name | Phone | Badge | |
|---|---|---|---|---|
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add more emergency personnel
add more person(s) involved
Was a witness present?
Witnesses List
| First Name | Last Name | Phone | |||
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Witness Status
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Description of Accident
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add more witnesses
delete recently added witnesses
Employee Completing Report
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Description of Accident
*Communication and Notification
(Click each user that should be notified of the accident)