Workplace Accident Report Form
Organization Information
Organization Name
Location / Department
Employee Information
Employee Name
Employee ID
Job Title
Supervisor Name
Accident Details
Date of Accident
Time of Accident
Accident Location
Describe What Happened
Nature of Injury (if any)
Names of Witnesses (if any)
First Aid or Medical Attention Provided
Other Information
Reported To (Name & Title)
Date of Report
Additional Comments