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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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Common mistakes
Filling out an Employee Accident Report form is crucial for documenting workplace incidents. However, many individuals make common mistakes that can lead to complications in the claims process. One frequent error is failing to provide complete information. Omitting details about the accident, such as the time, location, and specific circumstances, can hinder the investigation and resolution.
Another mistake involves not including witness statements. If there were colleagues present during the incident, their accounts can provide valuable context. Neglecting to gather this information can weaken the report and leave out important perspectives.
Inaccurate descriptions of the injury itself can also pose problems. Individuals may downplay or exaggerate their injuries, which can lead to discrepancies in medical evaluations. It is essential to document injuries factually and without bias.
Timing is critical when submitting the report. Delaying the completion of the form can result in lost details and may raise questions about the legitimacy of the claim. It is advisable to fill out the report as soon as possible after the incident.
Some people forget to sign and date the report. A signature is a confirmation that the information provided is accurate to the best of the individual’s knowledge. Without it, the report may be considered incomplete.
Additionally, failing to follow company procedures can create issues. Each organization may have specific guidelines for reporting accidents. Ignoring these protocols can lead to delays or even denial of claims.
Another common mistake is neglecting to communicate with supervisors or HR personnel. Keeping these parties informed about the accident and the report is essential for ensuring proper follow-up and support.
People often overlook the importance of keeping a copy of the report for their records. Having a personal copy can be beneficial for future reference, especially if disputes arise regarding the incident.
Lastly, many individuals do not seek medical attention promptly after an accident. Even if injuries seem minor, it is crucial to get evaluated by a healthcare professional. This not only ensures proper treatment but also creates a medical record that can support any claims made in the report.
Dos and Don'ts
Filling out an Employee Accident Report form is an important task that requires attention to detail. Here are some guidelines to help ensure the process goes smoothly.
Things You Should Do:
- Provide accurate and detailed information about the accident.
- Include the names and contact information of any witnesses.
- Describe the events leading up to the accident clearly.
- Submit the report as soon as possible after the incident.
Things You Shouldn't Do:
- Avoid making assumptions about what caused the accident.
- Do not leave out important details, even if they seem minor.
- Refrain from using vague language that could confuse the reader.
- Do not delay in reporting the incident to your supervisor.
By following these guidelines, you can help ensure that the report is effective and that all necessary information is communicated clearly.
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Similar forms
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Medical Report: A medical report provides details about an employee's injuries and treatment. It is similar to the Employee Accident Report in that both documents detail the consequences of the accident.
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Investigation Report: Following an accident, an investigation report is often created to analyze the causes. This document, like the Employee Accident Report, aims to prevent future occurrences by identifying what went wrong.
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