Hospital Staff Accident Documentation Sheet
Staff Information
Name
Department/Unit
Position/Job Title
Date of Accident
Time of Accident
Location (specific area)
Accident Details
Describe how the accident occurred
Names of all witnesses (if any)
Type of Accident
Slip/Fall
Needle Stick
Cut
Chemical Exposure
Assault
Other
Describe any injury sustained
Immediate Action Taken
First aid/treatment given
Person notified (Supervisor/Manager)
Was medical care required?
Yes
No
Additional Notes/Comments
Reported by (Name & Signature)
Date Reported