Scaffold Accident Report Form
General Information
Date of Incident
Time of Incident
Location/Area
Reported By
Contact Information
Incident Details
Describe the Accident
Witnesses (names/contact)
Weather Conditions
Injury & Damage Details
Injuries Sustained (if any)
First Aid/Treatment Provided
Damage to Scaffold/Property
Cause and Prevention
Cause of Accident (if known)
Corrective/Preventive Actions Taken
Supervisor Review
Supervisor Name
Supervisor Comments
Date of Review
Signature