Office of Risk Management
Incident, Accident or Unsafe Condition Report
< Print Form to Complete by Hand
Accident Information
Department:
* Required
Agency/Division:
* Required
Date of Accident:
* Required
Time of Accident:
am
pm
* Required
Type:
Accident
Incident
Unsafe Condition
Location of Accident, Incident, or Unsafe Condition:
* Required
Employee Completing Report
Name:
* Required
DOB:
(MM/DD/YYYY)
* Required
Title:
* Required
Employment Status:
Temporary
Permanent
* Required
Work Phone:
Ex. (555)555-5555
* Required
Home Phone:
Ex. (555)555-5555
* Required
Person Involved in the Accident or Incident
Name:
* Required
DOB:
(MM/DD/YYYY)
* Required
Address:
* Required
Home Phone:
Ex. (555)555-5555
* Required
Occupation:
* Required
Business Address:
* Required
Business Phone:
Ex. (555)555-5555
* Required
What was the person involved doing at the time of the accident or incident:
Injury
What was the nature and extent of the injury?
Was first-aid administered?
Yes
No
If yes, by whom?
Describe the type of first-aid treatment given:
Was medical treatment administered?
Yes
No
If yes, by whom?
Name and address of medical facility:
Did accident result in fatality?
Yes
No
* Required
Property Damage
Owner:
(include address and phone)
* Required
Damage Description:
(include estimated repair costs)
* Required
Witnesses
Name:
(include address and phone)
Name:
(include address and phone)
Accident Description
Describe in detail:
* Required
Include Pictures Here:
Legal
Was Law Enforcement Contacted?
Yes
No
* Required
Name of Law Enforcement Agency:
Signature
Signature:
(type name in signature box)
* Required
Date:
* Required
