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Accident/Injury Report
You are here:
Home
Accident/Injury Report
Accident/Injury Report
*
Accident Report
Near Miss
Name of Injured
*
Please choose the appropriate category
*
Employee
Student
Visitor
SID #
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Day Phone
*
Evening Phone
Date of Occurrence
*
Time
*
:
HH
MM
AM
PM
Location
*
Briefly describe what happened
*
What were you doing at the time, and if injured, what
caused
the injury?
Why did the accident happen?
Unsafe workplace conditions: (Check all that apply)
*
Inadequate guard
Unguarded hazard
Safety device is defective
Tool or equipment defective
Workstation layout is hazardous
Unsafe lighting
Unsafe ventilation
Lack of needed personal protective equipment
Lack of appropriate equipment/tools
Unsafe clothing
No training or insufficient training
Not Applicable
Other
If other, please specify
*
Unsafe acts by people: (Check all that apply)
*
Operating without permission
Operating at unsafe speed
Servicing equipment that has power to it
Making a safety device inoperative
Using defective equipment
Using equipment in an unapproved way
Unsafe lifting by hand
Taking an unsafe position or posture
Distraction, teasing, horseplay
Failure to wear personal protective equipment
Failure to use the available equipment/tools
Not Applicable
Other
If other, please specify
*
Was anyone else involved?
*
Yes
No
Name (Person Involved)
First
Last
Explain and provide names
Were you injured?
*
Yes
No
Describe your specific injury
*
Was first-aid provided?
*
Yes
No
What type of first-aid provided?
By whom
*
Was medical attention provided?
*
Yes
No
Name of Medical Provider (e.e. EMT, hospital, clinic, etc.)
*
What do you think could be done to prevent this from happening again?
Name of Supervisor/Instructor (if applicable)
Were they notified?
Yes
No
Was protective equipment used?
No
Yes
Not applicable
Explain availability/necessity/requirement of equipment
Was college property damaged?
No
Yes
If yes, explain
Signature of Individual Completing Form
Name
Date
Individual Completing Form
Witness
Supervisor
Injured Party
