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Accident Incident Report
Accident Incident Report
Report Date:
State:
Severity:
SECTION 1: INCIDENT DETAILS
Date: ________________ Time: ________Location: ________________________________
Severity: ________________
Description:
________________________________
Immediate Actions Taken:
________________________________
SECTION 2: INJURY INFORMATION
Injury Type: ________________Body Part Affected: ________________
Medical Treatment Sought: ________
SECTION 3: PEOPLE INVOLVED
SECTION 4: WITNESSES
No witnesses identified.SECTION 5: ROOT CAUSE ANALYSIS
Root Cause:
________________________________
Corrective Actions Planned:
________________________________
Frequently Asked Questions
Accident Incident Report