B&B Maintenance, Inc. Accident General Reporting Form 2.0

B and B Maintenance, Inc. Safety Reporting Form

This form is used to report all workplace safety related information. Accidents, incidents, near misses, and unsafe situations can be reported here.
Click Here if you need a reminder on the different types of accidents.
Are you reporting an Accident, an Incident, or an Unsafe Situation?

B and B Maintenance, Inc. Workplace Accident Report

Please complete this form in its entirety to the best of your ability. Any questions should be directed toward the EHS Director.
Current Date & Time:*

MonthDayYear
Date
Hour MinutesAM/PM Option
What type of accident are you reporting?*

Near MissMinor AccidentMajor Accident
What is your full name?*

First NameLast Name
Your Phone Number
Please enter a valid phone number.
Your Email Address
example@example.com
Are you the:*

ManagerSupervisorInjured Worker (IW)WitnessOther

Near Miss Reporting Form
A near-miss is a potential hazard or incident in which no property was damaged and no personal injury was sustained, but where, given a slight shift in time or position, damage or injury easily could have occurred. Near misses also may be referred to as close calls, near accidents, or injury-free events. For the sake of a safe work environment, the company asks that all employees report and correct any of these potential hazards immediately.

Please use this form to report near-misses and assist us in preventing future incidents and making our company a safer workplace.
Date/Time of Near Miss

MonthDayYear
Date
Hour MinutesAM/PM Option
Type of Near Miss
Address of Near Miss

Street Address

Street Address Line 2

CityState

Zip Code
Describe the potential incident/hazard/concern and possible outcome for this near miss.
Were safety procedures violated?

YesNo
Incident site inspection – Why was an unsafe act committed, or why was the unsafe condition committed?
Recommendations/steps to take to prevent a similar incident?
Near Miss - Upload any supporting documents.

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Section A - Injured Worker Information

If information is unknown, please leave it blank and EHS will follow up shortly. All of the requested information below is in regards to the IW. (IW = Injured Worker)
IW's Full Name:*

First NameLast Name
IW's Company Code/Department:
IW's Gender:*
IW's Current Address:

Street Address

Street Address Line 2

CityState

Zip Code
IW's Main Phone Number:
Please enter a valid phone number.
Who is the IW's direct Supervisor?
IW's Normal Shifts:
IW Job Title:

ManagerSupervisorCleaner
IW Type of Employment:
IW Current Pay Rate:
IW Date of Birth:

MonthDayYear
Date
IW Date of Hire:

MonthDayYear
Date

Section B - Accident Analysis

Manager/Supervisor to Complete
Date & Time of Accident:*

MonthDayYear
Date
Hour MinutesAM/PM Option
Address of Accident

Street Address

Street Address Line 2

CityState

Zip Code
When was the injury reported?*

MonthDayYear
Date
Hour MinutesAM/PM Option
Do you know of any witnesses?*
Names of Witnesses:
IW Body Part Affected:*
If "Other" please explain: (1)
If needed, 2nd body part effected for IW:
If "Other" please explain: (2)
IW Accident Type:*
If "Other" please explain: (3)
IW Immediate Cause:*
If "Other" please explain: (4)
In your own words, describe what happened:*
Did the injured employee seek medical treatment?*
Where did the injuired worker seek medical treatment?
If so, how did the injured worker travel to the facility?
Did the injured employee lose any time from work?*
Did the injured employee get placed on modified duty?

Section C - Employee Statement

IW to Complete
Your Gender:*
Your Date of Birth:*

MonthDayYear
Date
Your Current Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
When did the injury occur?*

MonthDayYear
Date
Hour MinutesAM/PM Option
When did you report the accident?*

MonthDayYear
Date
Hour MinutesAM/PM Option
This is what happened:*
Do you recall anything unusual or unexpected that happened?*
Are there work conditions which contributed to this injury?*
How would you explain why you were injured?*
Body Part Affected:*
If Other - Please Explain: (4)
If needed, 2nd body part effected:
If Other - Please Explain: (5)
Accident Type:*
If Other - Please Explain: (6)
When did you first notice the injury or illness?*
Did the pain develop suddenly or gradually?*
When did you first notice the pain?*
Have you ever had this pain before?*
If so, when and how often?
Are you taking time off of work due to this accident?*
If you are taking time off of work, is there a doctor's note stating this?
Do you wish to seek medical treatment?*
If you already have been treated, what facility did you go to?
Please list the name, address, and phone number of the facility.

Section D - Refusal of Medical Treatment Form
Only complete this section if the injured worker is refusing medical treatment.

I hereby acknowledge my refusal of medical treatment and/or observation offered to me by my employer, B and B Maintenance, Inc. for the work-related injury that I incurred. By signing this form, I realize that I may or may not affect my later eligibility for Workers’ Compensation.

I acknowledge that my supervisor, in good faith, has offered and made available to me an opportunity to seek necessary medical treatment and/or observation. I am aware that by declining medical treatment at this time, that my employer will not be responsible for any medical expenses or lost wages if treatment is obtained after the form is signed.

At a later time, I may request from the EHS Department at B and B Maintenance, Inc., via my supervisor, a medical authorization to obtain medical treatment and/or observation for the above described in jury. I understand that I will need an medical authorization form signed by the EHS Manager to seek any medical treatment due to the above incident after this refusal is signed.
Refusal of Medical Treatment Signature

Clear
By typing my name above, I consent to an electronic signature and I conclude that all facts stated above in regards to the workplace accident are true and I will be able to answer any other necessary questions from B and B Maintenance, Inc. if need be.
Today's Date: (2)

MonthDayYear
Date

Section E - Witness Accident Report

Supporting Witness to Complete
Witness Current Home Address:

Street Address

Street Address Line 2

CityState

Zip Code
Witness Direct Phone Number:*
Did you see the accident?*
When did it occur?*

MonthDayYear
Date
Hour MinutesAM/PM Option
Who is the injured worker?*
WIT Body Part Affected:*
WIT If Other - Please Explain: (1)
WIT If needed, 2nd body part effected:
WIT If Other - Please Explain: (2)
WIT Accident Type:*
WIT If Other - Please Explain: (3)
Where did it happen?*
Where were you in relation to the accident?*
Was anyone injured? If so, whom?*
Describe exactly what happened?*
Was the injured worker taken by ambulance?*
If so, who transported?
Did the injured worker appear to be under the influence of drugs?*
Did the injured worker appear to be under the influence of alcohol?*
Do you have any relation to anyone involved?*
If yes, whom?
Name any other witnesses that you know of:
Do you have any other necessary comments in regards to this accident?

Comments
Do you have any other comments on this safety situation?
Signature*

Clear
By signing my name above, I consent to an electronic signature and I conclude that all facts stated above in regards to the workplace accident are true and I will be able to answer any other necessary questions from B and B Maintenance, Inc. if need be.

Report an Unsafe Situation
Describe the Unsafe Situation*
What is the address of this jobsite?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please upload any pictures/documents of the unsafe situation.

Cancelof

Should be Empty:

B and B Maintenance, Inc. Safety Reporting Form

B and B Maintenance, Inc. Workplace Accident Report

Near Miss Reporting Form

Section A - Injured Worker Information

Section B - Accident Analysis

Section C - Employee Statement

Section D - Refusal of Medical Treatment Form

Section E - Witness Accident Report

Comments

B and B Maintenance, Inc. Workplace Incident Report

Section A - Report Information

Report an Unsafe Situation