Personnel Incident/accident Report Form printable pdf download

Personnel Incident/accident Report Form

Personnel Incident/Accident Report Form

Reporting a (circle one): Incident

Accident

Person Involved: ____________________________________________________ Male: _______ Female:_______

(Last Name)

(First Name)

(Middle Initial)

Local Home Address: _______________________________ City: _____________________ Zip: _____________

Birth Date: ____/____/____ Phone: ______________ Job Title: _____________________

If Employee

Time of accident/incident: ___________ am/pm

Social Security Number: ______- ______-______

Date of accident/incident: ____/____/____

Date of Hire: ____/____/____

Equipment involved:  Aircraft

 Vehicle

Years of Experience in Present Position: _________

 None

 _______________

Equipment description: Type ____________________

Time employee began work: ____________ am/pm

Color ______________________

N-Number / Tag ____________________

Where did the incident occur? Building: ______________ Apron: __________ Other: _______________

What was the victim doing just before the accident/incident occurred? Describe the activity, as well as the tools,

equipment or material the victim was using. Be specific. Examples: “climbing a ladder while carrying roofing

materials”; “Fueling specific aircraft”; “Mowing taxiway on John Deer.” ; “Walking though North hallway.”

What happened? Tell us how the accident/incident occurred. Examples: “Worker was sprayed with gas when

gasket broke during replacement”; “Customer developed shortness of breath.”

Names and addresses of witnesses to the accident/incident.

Name

Address

Phone

Page 1 of 3

Personnel Incident/accident Report Form