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Workplace Accident Report Form Template

Author: Novade Solutions

Compliance with HSE is critical for every construction business. Use this Workplace Accident Report form template to keep track and report accidents on-site.

Published on: 7/15/2021

Accident report

General Information

Company name

Project title

Location

Contract no.

Details

1.Name of employer

2.Site address

3.Contact name

4.Injured person’s surname

5.Forenames

6.Injured person’s address

7.Normal occupation

8.Date of birth

9.Occupation at time of accident

10.Exact location of accident

11.Date and time of accident

12.Date and time of ceasing work

13.Precise nature of injury(if eye or limb, state left or right)

14.To whom was the accident reported?

15.Date and time of the accident reported?

16.HSE or Incident Contact Centre informed by telephone or online

17.Date and Time of HSE or Incident Contact Centre informed

18.Date and Time of F2508 report sent to the HSE

*19.Accident recorded in the official company register (if applicable)

*20.Was first aid given on site? If ‘Yes’ state name of first aider

21.If treatment was received from a doctor, state doctor’s name

*22.Did the injured person go to hospital?

23.If the injured person went to hospital, give the name of Hospital

*24.Was the injured person authorised to be at the place of the accident for the purpose of their work?

*25.Was the injured person authorised to be at the place of the accident for the purpose of their work?

26.How was the accident caused? Give a full description of what happened.

27.State what the injured person was doing at the time.

28.If the person fell from height or into an excavation, state distance of fall in metres

29.What action has been taken to prevent a recurrence?

30.Was machinery involved? If yes, Give name and number of machine or part involved in the accident.

*31. Was it working at the time of the accident?

32.Names and addresses of witnesses to the accident (always obtain witnesses, where possible)

*33.Use a separate sheet of paper for a sketch plan of the scene

To be completed by Head Office

*Further medical reports on injured person

*Injured person ceased employment

New address for injured person

*Is a further investigation report required?

*Have control measures been implemented to prevent a reoccurrence?

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