Accident Report
Report Date
/
Month
/
Day
Year
Date
Report Time
Reporters Name
Reporters Phone Number
Please enter a valid phone number.
Reporters Email
example@example.com
Accident Date
/
Month
/
Day
Year
Date
Accident Time
Location of Accident
Type of Accident
Injury
Property Damage
Other
Name(s) of Individual(s) Involved & Contact Information
Role/Relation to Organization:
Staff
Volunteer
Member/Participant
Visitor
Other
Names of Witnesses
Contact Number of Witness(es):
Witness(es)Email
example@example.com
Detailed Description of Accident: (Please provide a thorough account of the accident, including actions leading up to the accident, the accident itself, and any immediate actions taken
Please describe any immediate actions taken in response to the accident such as first aid, contacting emergency services, etc
Description of Injuries (if any): (Please detail the nature and extent of any injuries sustained in the accident
Was medical treatment provided?
Yes
No
If Yes specify the type of treatment and by whom
Follow Up Actions Required: (Please describe any further actions required, such as follow up with involved individuals, repairs, additional reporting, etc
Was the accident reported to any authorities?
Yes
No
If Yes, specify the authority and the date reported:
Additional Notes or Comments
Reviewed By
Date of Review
/
Month
/
Day
Year
Date
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