Workplace Accident Incident Report
General Information
Date of Report
Report Prepared By
Accident Details
Date of Accident
Time of Accident
Location of Accident
Description of Accident
Persons Involved
Name
Job Title
Department
Injury Details
Nature of Injury
Body Part(s) Affected
First Aid Provided
Medical Treatment Required
Witnesses
Name(s) of Witness(es)
Immediate Action Taken
Root Cause Analysis
Corrective Actions / Recommendations
Supervisor Review
Name
Date
Comments