Staff Accident/Incident Report Form

Fm.A.A.01.08

.

Name: *

Date of Incident: *

Department: *

Date of Report: *

Role: *

Time of Incident: *

Incident type:

AccidentIncidentNear Miss

Location:

Witnesses

Reported to whom:

Date Reported:

Time:

Full Description of the Incident:

Other Injury - please list:

Injury Summary

Lost Time

YesNo

No. of Days:

Workers Compensation Claim

YesNo

Describe Damage:

Describe Contributing Factors

Immediate Corrective Action:

Controls/Corrective Measures - what can be put in place to prevent this from reoccurring:

Recommendations for Action:

Who is to implement these controls/corrective measures:

Date by which action to be taken:

Department Manager:

Draw signature|Type signatureClear

Date signed by Manager:

Date Updated: October 2023 N:\Forms\Adminitration\FM_A_A_01.08