Accident/incident report form

Employee name:
Pierna
Employee position:
Office Administrator
Location of accident:
Storeroom
Date/time of Accident:
4:00 8/1/2016
Severity of incident:
Crush Injury
Accident reported to:
Safety Manager
Nature of Injury:
Crushed toes
Eye-witnesses:
Ashleigh Heard the box fall.

Account of Accident:
Pierna was placing a box back on the shelf when she bumped
another box which fell on her toes
Cause of Accident:
Heavy Boxes, poorly lit storeroom, boxes are stored to high and
opened toed shoes were worn
Description of Injuries:
Crushed toes
Steps taken to prevent accident reoccurring:
Improve lighting, store heavy boxes lower down, Introduce closed
shoe policy and take paper out of boxes

Personal details of reporter:

Lachlan Rees