Employee Accident/Incident Report Form

1
Employee Name* This field is required.
First Name
Last Name
2
Employee Phone Number* This field is required.
Area Code
Phone Number
3
Employee Email* This field is required.
example@example.com
4
Date of incident/Accident* This field is required.
Date
Month
Day
Year
5
Time of incident/Accident* This field is required.
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
10
20
30
40
50
Minutes
AM
AM
PM
6
Route Number
7
Stop Number
8
TBA Number of Delivery Closest to Incident
9
Location* This field is required.
10
Location description* This field is required.
Customer’s Driveway
Customer’s House
Customer’s Yard
Office area
Road
Van
Warehouse
Other
11
Area conditions* This field is required.
Ice, sleet, snow, freezing
Rain
Restricted space
Rubbish, debris, general untidiness
Sunny and fair
Tidy, well lit, no obstructions
Other
12
Which task was being performed at the time of the incident/Accident?* This field is required.
Delivering
Driving
Loading
Office Work
Packing
Picking
Put away
Unloading
13
Which type movement was being used at the time?* This field is required.
Bending
Entering Van
Exiting Van
Lifting
Repetitive movement
Stair stepping
Turning
Twisting
Walking
14
Description of Incident/Accident* This field is required.
15
Download Picture(s) Here
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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16
Were there any witnesses?* This field is required.
YESNO
17
First witness name
18
First witness phone number
Area Code
Phone Number
19
Second witness name
20
Second witness phone number
Area Code
Phone Number
21
Employee's vehicle license plate
22
Other party's vehicle license plate
23
Other party's driver's license number
24
Were the police called?* This field is required.
YESNO
25
Police officer name and ID
26
Were you injured?* This field is required.
YESNO
27
DA injurey: body part(s)
Ankle, Left
Ankle, Right
Arm, Left
Arm, Right
Back
Bottom
Chest
Foot, Left
Foot, Right
Hand, Left
Hand, Right
Head
Groin
Knee, Left
Knee, Right
Neck
Shoulder, Left
Shoulder, Right
28
How would you rate your level of pain?* This field is required.
0 None
1
2
3
4 Most severe
29
Did you continue working?
YESNO
30
Describe your injury, if any
31
Was the other party injured?* This field is required.
YESNO
32
Other party's injury: body part
N/A
Ankle, Left
Ankle, Right
Arm, Left
Arm, Right
Back
Bottom
Chest
Foot, Left
Foot, Right
Hand, Left
Hand, Right
Head
Groin
Knee, Left
Knee, Right
Neck
Shoulder, Left
Shoulder, Right
33
Describe the other party's injury, if any
34
Was an ambulance called?* This field is required.
YESNO
35
Ambulance ID
36
Did either party seek medical attention?* This field is required.
YESNO
37
Medical facility used
38
Was your vehicle or company property damaged?* This field is required.
YESNO
39
Description of damage to your vehicle or company property
40
Was the other party's vehicle or property damaged?* This field is required.
YESNO
41
Description of damage to other party's vehicle or property
42
Employee Explanation/Notes
43
Is Employee's training up to date?* This field is required.
YESNO
44
Was the appropriate PPE worn?* This field is required.
YESNO
45
Describe the root cause of the incident* This field is required.
46
What corrective actions can prevent re-occurrence?* This field is required.
47
Employee Date of Hire
Date
Year
Month
Day
48
Employee Last Date of Training
Date
Year
Month
Day
49
Name of Person Filing Report* This field is required.
First Name
Last Name
50
Phone of Person Filing Report* This field is required.
Area Code
Phone Number
51
Email of Person Filing Report* This field is required.
example@example.com
Should be Empty: