Accident Report

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

MonthDayYearHourMinutesAM/PM Option
Date Reported*
Type of Incident*

Near MissProperty Damage; No InjuriesReport Only - Medical Treatment Refused by EEFirst AidMedical TreatmentLost TimeFatalityOther
Damaged Property Owner:
Injuries:*

YesNo
Medical Treatment Refused:*

YesNo
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*

Clear
Non-Injury Photos

Area/Damage/Weather
Upload a File

Cancelof
GMF Representative Name:*

First NameLast Name
GMF Representative Signature*

Clear
Should be Empty:

Incident / Accident Report