Accident Report Employer name Policy number Employee name Date of injury Claim number Report date Report completed by Job title Manner of Accident: (check one) Contact with objects or equipment Falls Bodily reaction and exertion (including repetitive motion, lifting, etc.) Exposure to harmful substances or environments Transportation accidents Fires and explosions Assaults and violent acts Other Fully describe the accident: Causal factors that contributed to accident: (Check all that apply and provide detailed description.) Environment: (weather, housekeeping, lighting, noise, temperature, etc.) Explain: ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ Human factor/Personal: (level of experience, level of training, physical capability, health, fatigue, stress, etc.) Explain: ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ BWC-1584 (pg. 1 of 2) DFSP-1 American LegalNet, Inc. www.FormsWorkFlow.com Causal factors that contributed to accident: (Check all that apply and provide detailed description.) Task: (ergonomics, condition changes, work process, safe work procedures, etc.) Explain: ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ Management/Process: (safety policies, enforcement, supervision, hazard correction, preventative maintenance, etc.) Explain: ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ Material/Equipment: (equipment failure, design, guarding, hazardous substances, etc.) Explain: ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ Preventative measures to be implemented: (Check all that apply.) Engineering control: (Design the facility, equipment, or process to eliminate or reduce exposure to a hazard.) Administrative control: (any procedure that minimizes exposure by controlling the manner in which work is performed or manipulation of the work schedule) Personal protective equipment (PPE): (reduces employee exposure to hazards when engineering and administrative controls are not feasible or effective in reducing these exposures to acceptable levels) Fully describe the specific actions that have or will be taken to prevent a similar accident from occurring again. Corrective actions should address causal factors identified above. X Signature BWC-1584 (pg. 2 of 2) DFSP-1 Date signed American LegalNet, Inc. www.FormsWorkFlow.com