Accident Report

Incident / Accident Report
GMF Job Name
Project
Date & Time of Accident:

MonthDayYearHourMinutesAM/PM Option
Date Reported
Type of Incident

Other
Damaged Property Owner:
Injuries:
Medical Treatment Refused:
Supervisor's Name:

First NameLast Name
Involved Employee's Name:

First NameLast Name
Involved Employee's Phone Number

Area CodePhone Number
Involved Employee's Job Title:
Position
Involved Employee's Hire Date:
Involved Employee's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Involved Employee's Experience (Years):
Location on Job:
Example: Area D; NW Corner
Description of Accident:
In Detail
If Injuried, describe in detail:
Be sure to include, Injury, Cause, body part affected
Incident Witness(es):
What were the immediate corrective actions?
Corrective Actions
What could have prevented this?
Preventative Measures
Involved Employee's Signature
Non-Injury Photos

Area/Damage/Weather
Upload a File

Cancelof
GMF Representative Name:

First NameLast Name
GMF Representative Signature
Should be Empty:

Incident / Accident Report