Accident/Injury Report

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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
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
Were there any witnesses to the accident and if so, who?
- Yes
- No
Witnesses
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