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Construction Accident Report
When you have an accident on your construction site this sample template of a report can be used to document the incident along with important information. This includes everything from resulting injuries to witnesses and a description. Getting this information in writing quickly and accurately is important any time an accident occurs.

Free Sample Template
Format: Word PDF
# of Pages: 3
Printable: Yes


Construction Accident Report TemplateForm 2275
Format: Word PDF
Category: Occupation, Construction
Type: Report

Construction Accident Report

Report Date: ___/___/_____

Accident Type:

Injury

Illness

Fatality

Property Damage

Environmental

Other:

Accident Involving:

Hazardous Material

Waterfront Operations

Electrical

Confined Space

Crane or Rigging

Demolition or Renovation

Equipment or Motor Vehicle

Trenching or Entrapment

Driving

Fire

Falls

Collapse

Other:

Personal Information:

Name: ________________________________________________________________________________________

Address: ______________________________________________________________________________________

City: ______________________________________ State: _____________ Zip Code: ________________________

Age: ____________ Sex: ____________ Social Security Number: _________________________________________

Job Title: _________________________ Employed By: _________________________________________________

Supervisorís Name: _____________________________________________________________________________




Witness Information:

Name: ________________________________________________________________________________________

Address: ______________________________________________________________________________________

City: ______________________________________ State: _____________ Zip Code: ________________________

Age: ____________ Sex: ____________ Social Security Number: _________________________________________

Job Title: _________________________ Employed By: _________________________________________________

General Information:

Date of Accident: ___/___/_____ Time of Accident: _____:_____ AM / PM

Location of Accident: ____________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Construction equipment involved in the accident: ____________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Safety Managerís Name: _________________________________________________________________________

Insurance Carrier: ______________________________________________________________________________

Work activity at the time of the accident: ____________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

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List personal protective equipment that was being used at the time of the accident: _________________________

_____________________________________________________________________________________________

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Accident Information:

Severity of Illness or Injury: _______________________________________________________________________

Number of Days Lost: ___________________________________________________________________________

Number of Days Hospitalized: _____________________________________________________________________

Number of Days Duty Restricted: __________________________________________________________________

Parts of Body Affected: __________________________________________________________________________

Nature of Illness or Injury: ________________________________________________________________________

Type and Source of Injury or Illness: ________________________________________________________________

Description of Accident: _________________________________________________________________________

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