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Employee Accident Report Preview
Employee Incident Investigation Report
Instructions: Complete this form as soon as possible after an incident that results in serious injury or illness.
(Optional: Use to investigate a minor injury or near miss that could have resulted in a serious injury or illness.)
This is a report of a: Death Lost Time Dr. Visit Only First Aid Only Near Miss
Date of incident:
This report is made by: Employee Supervisor Team Other_________
Step 1: Injured employee (complete this part for each injured employee)
Name: |
Sex: Male Female |
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Age: |
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Department: |
Job title at time of incident: |
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Part of body affected: (shade all that apply) |
Nature of injury: (most |
This employee works: |
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serious one) |
Regular full time |
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Abrasion, scrapes |
Regular part time |
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Amputation |
Seasonal |
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Broken bone |
Temporary |
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Bruise |
Months with |
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Burn (heat) |
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this employer |
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Burn (chemical) |
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Concussion (to the head) |
Months doing |
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Crushing Injury |
this job: |
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Cut, laceration, puncture |
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Hernia |
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Illness |
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Sprain, strain |
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Damage to a body system: |
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Other ___________ |
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Step 2: Describe the incident
Exact location of the incident:
Exact time:
What part of employee’s workday? Entering or leaving work |
Doing normal work activities |
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During meal period |
During break |
Working overtime Other___________________ |
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Names of witnesses (if any):
1
Number of attachments:
Written witness statements:
Photographs:
Maps / drawings:
What personal protective equipment was being used (if any)?
Describe,
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Description continued on attached sheets: |
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Step 3: Why did the incident happen? |
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Unsafe workplace conditions: (Check all that apply) |
Unsafe acts by people: (Check all that apply) |
Inadequate guard |
Operating without permission |
Unguarded hazard |
Operating at unsafe speed |
Safety device is defective |
Servicing equipment that has power to it |
Tool or equipment defective |
Making a safety device inoperative |
Workstation layout is hazardous |
Using defective equipment |
Unsafe lighting |
Using equipment in an unapproved way |
Unsafe ventilation |
Unsafe lifting |
Lack of needed personal protective equipment |
Taking an unsafe position or posture |
Lack of appropriate equipment / tools |
Distraction, teasing, horseplay |
Unsafe clothing |
Failure to wear personal protective equipment |
No training or insufficient training |
Failure to use the available equipment / tools |
Other: _____________________________ |
Other: __________________________________ |
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Why did the unsafe conditions exist?
Why did the unsafe acts occur?
Is there a reward (such as “the job can be done more quickly”, or “the product is less likely to be damaged”) that may
have encouraged the unsafe conditions or acts? Yes No If yes, describe:
Were the unsafe acts or conditions reported prior to the incident? |
Yes |
No |
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Have there been similar incidents or near misses prior to this one? |
Yes |
No |
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Step 4: How can future incidents be prevented?
What changes do you suggest to prevent this incident/near miss from happening again?
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Stop this activity |
Guard the hazard |
Train the employee(s) |
Train the supervisor(s) |
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Redesign task steps |
Redesign work station |
Write a new policy/rule |
Enforce existing policy |
Routinely inspect for the hazard Personal Protective Equipment Other: ____________________
What should be (or has been) done to carry out the suggestion(s) checked above?
Description continued on attached sheets:
Step 5: Who completed and reviewed this form? (Please Print)
Written by: |
Title: |
Department: |
Date: |
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Names of investigation team members: |
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Reviewed by:
Title:
Date:
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Documents used along the form
When an employee is involved in an accident at work, several documents may be necessary to ensure proper reporting, investigation, and follow-up. The Employee Accident Report form is just one piece of the puzzle. Below are other essential forms and documents that are often used in conjunction with this report.
- Incident Investigation Report: This document provides a detailed account of the accident, including the circumstances surrounding it, potential causes, and witness statements. It aims to identify any safety hazards and suggest corrective actions to prevent future incidents.
- Legal Compliance Checklist: This document ensures that all necessary legal requirements are met before filing essential forms, including the Articles of Incorporation, to establish a corporation in Illinois.
- Workers' Compensation Claim Form: If the employee requires medical treatment or misses work due to the accident, this form is necessary to initiate a claim for workers' compensation benefits. It collects information about the injury and its impact on the employee's ability to work.
- Medical Release Form: This form allows the employer to obtain medical records related to the employee's injury. It ensures compliance with privacy regulations while enabling the employer to understand the extent of the injury and the necessary accommodations for the employee.
- Return-to-Work Agreement: Once the employee is ready to return, this document outlines any modifications or accommodations needed for their reintegration into the workplace. It helps ensure a smooth transition and addresses any lingering concerns about their ability to perform job duties.
- Safety Training Records: These records document any safety training the employee has received. They can be useful in assessing whether the employee was adequately trained to handle the tasks they were performing at the time of the accident and can help identify gaps in training that need to be addressed.
Collectively, these documents help create a comprehensive understanding of workplace accidents. They facilitate not only the immediate response but also long-term strategies for improving workplace safety and compliance with regulations.
Similar forms
- Incident Report Form: This document captures details about any incident that occurs in the workplace. It includes information about the people involved, what happened, and when it took place, similar to the Employee Accident Report.
- Workers' Compensation Claim Form: This form is used to initiate a claim for benefits after a workplace injury. Like the Employee Accident Report, it requires details about the accident and the injuries sustained.
- Safety Incident Log: This log tracks all safety-related incidents within a company. It helps identify patterns and areas for improvement, much like the Employee Accident Report focuses on documenting specific accidents.
- Motor Vehicle Bill of Sale Form: For those involved in vehicle transactions, utilizing the comprehensive guide to Motor Vehicle Bill of Sale ensures all legal details are properly documented.
- First Aid Report: When first aid is administered following an injury, this report details the treatment given. It parallels the Employee Accident Report by documenting the immediate response to an accident.
- Return-to-Work Agreement: This document outlines the terms under which an injured employee can return to work. It relates to the Employee Accident Report as it follows the documentation of an injury and ensures the employee's safe reintegration.
- Safety Training Records: These records document the safety training provided to employees. They are similar to the Employee Accident Report in that they aim to prevent future incidents by ensuring all employees are informed about safety protocols.
Misconceptions
Understanding the Employee Accident Report form is crucial for both employees and employers. However, several misconceptions can lead to confusion about its purpose and use. Here are eight common misconceptions:
- The form is only for serious injuries. Many people believe that the report is necessary only for severe accidents. In reality, it should be completed for any workplace incident, regardless of the injury's severity, to ensure proper documentation and follow-up.
- Filing a report will lead to disciplinary action. Some employees fear that submitting an accident report will result in punishment. The form is intended to promote safety and prevent future incidents, not to penalize individuals.
- The report is optional. Some employees think that completing the report is not mandatory. In fact, most employers require it to comply with safety regulations and maintain accurate records.
- Only the injured employee can fill out the report. While the injured party should provide their account, witnesses can also contribute valuable information. Their input can help create a more comprehensive understanding of the incident.
- The report is only needed for insurance claims. Although the report may assist in filing claims, its primary purpose is to document the incident for safety analysis and prevention, not just for financial purposes.
- Submitting the report is enough to resolve the issue. Completing the form is just the first step. Employers must take further action to address safety concerns and implement necessary changes.
- Accident reports are confidential and never shared. While personal details may be kept confidential, the information can be shared with relevant parties for safety training and compliance purposes.
- Accident reports can be altered after submission. Once submitted, reports should remain unchanged to maintain accuracy. Altering details can lead to complications in investigations and future safety measures.
Being aware of these misconceptions can help create a safer work environment and encourage open communication about workplace incidents.
Understanding Employee Accident Report
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What is the Employee Accident Report form?
The Employee Accident Report form is a document used by employers to record details about accidents or injuries that occur in the workplace. It serves to document the circumstances surrounding the incident, including the nature of the injury, the location, and any witnesses present. This report is essential for both legal compliance and for improving workplace safety.
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Why is it important to complete the form?
Completing the form is crucial for several reasons. First, it helps ensure that the incident is officially recorded, which is important for workers' compensation claims. Second, it allows the employer to investigate the incident, identify hazards, and implement safety measures to prevent future accidents. Lastly, having a documented account can protect both the employee and employer in case of disputes.
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Who should fill out the Employee Accident Report form?
The employee involved in the accident should fill out the form, providing their perspective on what occurred. Additionally, a supervisor or manager may also be required to complete a section of the form, especially to provide an objective account and any additional information that may be relevant.
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What information is typically required on the form?
The form usually requires the following information:
- The date and time of the accident.
- The location where the accident occurred.
- A detailed description of the incident.
- The nature of the injury sustained.
- Names and contact information of any witnesses.
- Any immediate actions taken after the accident.
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How soon should the form be completed?
It is recommended that the Employee Accident Report form be completed as soon as possible after the incident, ideally within 24 hours. Prompt reporting helps ensure that details are fresh in the minds of those involved, which increases the accuracy of the information recorded.
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What happens after the form is submitted?
After submission, the employer will review the report and may conduct an investigation into the incident. This may involve interviewing witnesses, examining the scene, and assessing safety protocols. The findings will help determine if any changes need to be made to improve workplace safety and prevent similar incidents in the future.
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Can the information on the form be kept confidential?
While the details of the report are generally kept within the company for internal use, there are legal obligations regarding privacy and confidentiality. Employers should handle the information sensitively and limit access to those who need it for legitimate purposes, such as safety reviews or workers' compensation claims.
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What if the employee disagrees with the report's contents?
If an employee disagrees with the contents of the report, they should communicate their concerns to their supervisor or the designated safety officer. Employers often allow employees to submit additional comments or documentation to clarify their perspective. It's important for all parties to have a clear and accurate account of the incident.