Accident / Incident Report Form
(to be completed by site Team Leader/Supervisor immediately following accident/incident and forwarded to Company Safety Officer)
  Project / Location
  Address
  Team Leader / Supervisor
  Employee Contractor
  Name
  Address
  Telephone Bus
  A.H  
  Mobile  
  Date of Accident / Incident
  Time  
  Location of Accident / Incident
  Description of Accident / Incident
  Witnesses Names / Addresses
  Description of Injuries Resulting
  Description of Property Damage
  Action Taken Immediately Following
  Accident / Incident
  Name and Address of Hospital /
  Medical Centre / Doctor
  Outcome of Accident/Incident
  Rehabilitation     Yes / No
  Period of Rehabilitation
  Time Required Off Work
  Accident / Incident Causes
  Corrective Action To Be Taken
  Signature
  Investigating Officer
  Title  
  Date  
  Supervisor / Team Leader
  Date  
  Employee / Contractor
  Date