Accident icon
Accident Report

Instructions for completing the form.

Date of Accident

Accident date picker icon. *

Time of Accident

Accident time picker icon. *
*
*
*
Severity: *

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 Email Phone
Delete person involved.
Person(s) Involved
Affiliation
*
 
*
*
*
*
*
*
*
*
*
*
*
Person Involved Date of Birth date picker icon. *
*
*
*
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

              Human body wireframe.
              • Body part head selected.
              • Body part left hand selected.
              • Body part right hand selected.
              • Body part abdomen selected.
              • Body part left leg selected.
              • Body part right hand selected.
              No Injury Added

              Suspected Injury List

              Type of Injury Body Part Injury Action Taken
              Delete Injury
              Add Injury Add Injury
              *
              *
              *
              *

              Refused Care Statement

              Self Care Statement

              Emergency Personnel List

              First Name Last Name Phone Badge
              Delete Emergency Personnel.
              911 Time Called timepicker icon *
              911 Time Arrival timepicker icon *
              911 Time Departure timepicker icon *
              *
              *
              *
              *
              *
              *
              Add Emergency Personnel. add more emergency personnel
              Sr. NO. File Name Type Size
              View photo.
              Sr. NO. File Name Type Size
              Add person involved. add more person(s) involved

              Was a witness present?

              Witnesses List

              First Name Last Name Email Phone
              Edit this witness. Delete this witness.

              Witness Status

              *
              *
              *
              *
              *
              *

              Description of Accident

              *
              Add Witness. add more witnesses
              Delete Recently Added Witness. delete recently added witnesses

              Employee Completing Report

              *
              *
              *
              *
              *
              *

              Description of Accident

              *
              Communication and Notification

              (Click each user that should be notified of the accident)

              Custom Questions