Accident/ Incident Report
Please fill out this form completely for any safety-related incident occurring while serving as a volunteer, whether or not the incident resulted in injury. Complete the form as soon as possible after the incident. In completing the form, provide as much detail as possible including time of occurrence, location, general physical conditions present, witnesses, and any other relevant information. Use the bottom and back of this form to add detail, draw diagrams, etc
Current Email:
Your answer
Volunteer: *
Your answer
Department/Position: *
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Date *
MM
/
DD
/
YYYY
Time of Accident: *
Time
:
Specific location of incident: *
Your answer
Witnesses present: *
Your answer
Description of incident (use as much detail as possible, including diagrams): *
Your answer
Cause if incident (include tools, objects, chemicals, etc., and specify the items that directly caused the injury): *
Your answer
Injury caused by incident (include potential injury, such as a sprained ankle, a strained back, etc.): *
Your answer
Recommendations (describe the control and/ or corrective action procedures): *
Your answer
Report completed by: *
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Submit
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