Accident Report

Please type in all information.

Today's date:

First name:        Last name:

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Details of Accident or Injury

Date and hour of accident. (day/mo/yr/time) Date and hour reported to the Supervisor (if after the fact) (day/mo/yr/time)

Where was the person when the accident or injury happened?

To whom was the accident reported? (Name) If it was not reported immediately, give a reason.

What happened to cause the accident/injury? Describe the injury, the part of the body injured and tell right or left side.

Describe the person's activities at the time of the accident/injury. Tell the equipment or materials used and the size and weight of objects being used.

Is there anyone else who may have seen or who may know about the accident or injury? If so, provide the information below. Name(s) Address(es) and phone number(s) if available.

Health Care

What medical attention or first aid treatment was given to the injured person? List the name of the medical professional or first aid provider.

When you are finished, please ask your teacher to look at this form. Thanks.