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Accident / Incident Report Form Template
EMPLOYEE
NAME:

TITLE / ROLE:

DATE OF REPORT:

EMPLOYEE
SIGNATURE:

LENGTH OF TIME
IN CURRENT ROLE:

DATE OF INCIDENT:

LOCATION OF
INCIDENT:

TIME OF
INCIDENT:

RESULT OF ACCIDENT / INCIDENT
HEAD

LEFT

FACE

SHOULDER

NECK

ARM PIT

UPPER BACK

UPPER ARM

LOWER BACK

LOWER ARM

CHEST

ELBOW

ABDOMEN

WRIST

PELVIS / GROIN

HAND

LIPS

BUTTOCKS

TEETH

HIP

TONGUE

THIGH

NOSE

LOWER LEG

FINGERS

KNEE

TOES

ANKLE

OTHER:

EYES

OTHER:

EARS

INCIDENT INFORMATION
RIGHT
INCIDENT
DESCRIPTION

TASKS LEADING
TO INCIDENT
ADDITIONAL
INFORMATION
OSHA
REPORTING

WITNESS NAME
AND CONTACT