Workplace Accident and Injury Report

Workplace Accident and Injury Report — Form Fields

This hr template includes 10 fields. Employees report workplace accidents, injuries, or near misses to HR and safety teams. Free to customize and use on ZenBuild.

• Injured Employee Name (text, required)
• Employee ID (text, required)
• Department (text, required)
• Date and Time of Incident (text, required)
• Location of Incident (text, required)
• Type of Incident (dropdown selection, required) — options: Slip or Fall, Struck by Object, Repetitive Motion Injury, Chemical Exposure, Near Miss, Vehicle Accident
• Detailed Description of What Happened (long text, required)
• Was medical treatment required? (multiple choice, required) — options: Yes - Emergency Room, Yes - Clinic Visit, First Aid Only, No Treatment Needed
• Witness Names (if any) (text, optional)
• Recommended corrective actions (long text, optional)