Click Here For Frequently Asked QuestionsAccident Incident Report

Please answer every question with as much detail as possible.

Person completing this report: Date report prepared:
Department: Telephone number:

Injured Party Information

Last Name: First Name:
NetID: Date of Hire:
N Number: Department:
next section

Accident Information

Date of notification: Date of incident:
Time of incident: AM PM
Notification occurred within 24 hours?
(If "No", please provide a reason) Yes No
What medical treatment did the employee receive? First Aid: Hospital: Other:
next section

Description of Incident

1. What was the exact location of the accident (building, floor, office, etc)?
2. Please give a detailed description of the accident.
next section

Description of Incident (continued)

3. Was the injury the result of the employee not following safety rules or Standard Operating Procedures (SOPs)? (If "Yes", please describe) Yes No
4. In your opinion, what was the root cause of the accident?
5. What exactly was the employee doing at the time of the accident (eg. lifting boxes, pushing cart, etc)?
6. Which body parts were injured (be specific, i.e. left elbow and wrist)?
next section

Description of Incident (continued)

7. Was the employee instructed to use protective equipment? Were they wearing appropriate PPE? Was PPE required to be used? (If "No", please describe) Yes No
8. What corrective measure will you take or implement to avoid another incident of this type?
9. Describe any contributing factors that may have been present (wet floors, snowy weather, controlled indoor environment, etc).
10. Do you have any questions or concerns regarding this claim?
(If "Yes", please describe) Yes No
11. Could the entire staff benefit from re-training? Yes No
12. What training was completed with the injured employee? Name of training: Date of training:
13. Did the employee receive a copy of FCM Work Rules? Yes No
next section

Nature of the Injury

Strain/sprain from:
Lifting/handling materials: Pushing/pulling: Reaching/twisting: Crawling/bending:
Struck by:
Falling/moving object: Tools/equipment: Stationary object: Person:
Puncture/Cut by:
Tools/equipment: Surface/object:
Exposure:
Temperature Extremes: Chemical: Foreign Object: Other:
Slip/Fall:
Wet Surface: Ice/Weather: Stairs: Uneven Surfaces: Over Objects: From Heights: Other:
next section

Additional Information

Were pictures taken of the accident scene? Yes No
Do you have witness statements? Yes No
Is this an OSHA recordable? Yes No
Does this incident result in lost time? Yes No
Was a Public Safety Report completed? Yes No
If "Yes", what is the report number?
next section

Additional Comments:

Comments:
Report Completed by: N Number:
NetID: Date: submit