Incident / Accident Form (Supervisor)

Tractor #*

Trailer #*

Name*

Date of Birth*

Years of Service*

Date of Occurrence*

Date Reported to Supervisor*

Time*

: HH

MM

Exact location of incident*

Injury

Part of the body injured*

Type of injury*

Did you require medical attention?*

Yes
No

Who provided the service?*

Emergency
Doctor
First Aid

Did you cease work?*

Yes
No

Date Ceased Work*

Time Ceased Work*

: HH

MM

Description of Incident / Accident*

Is there any established procedure for this task?*

Yes
No

Was the procedure being followed?*

Yes
No

Was appropriate equipment provided?*

Yes
No

Was appropriate equipment used correctly?*

Yes
No

Why was the procedure not followed?*

What action could have prevented this occurrence?*

Was training provided for this task?*

Yes
No

To your knowledge, has there been any other incident / accident of this type before?*

Yes
No

How many and when?*

Employee Signature*

Witness Signature*

Date of Investigation*

Action taken to prevent occurrence*

OH&S Rep Signature*

Supervisor / Safety Manager Signature*

Incident/Accident

Form – Supervisor

Injury