SAMPLE INCIDENT/ACCIDENT REPORT FORM

- SAMPLE -

FARM ACCIDENT/INCIDENT REPORT FORM

{Farm Name}

Date of incident: _______________ Time: ________ AM/PM

Weather conditions: __________________________________

Name of injured person:

Address:

Phone Number(s):

Date of birth: ________ Male ______ Female _______

Description of injury:

________________________________________________________________________

Details of incident:

________________________________________________________________________

Were there any witnesses? Yes ___ No ___

Name of witness(es): ______________________________ _______

Address of witness: _____________________________________________________________

Phone number: _______________________________________

Was a witness statement obtained? Yes ___ No ___

Was first aid administered at the farm? Yes ___ No____

If yes, describe actions taken: _____________________________________________________

Did injury require EMS/hospital visit? Yes ___ No _____

Name of hospital:

Hospital phone number:

Employee investigating scene: ___________________________

Any corrective measures taken? ___________________________________________________

Any photographs taken? Yes ___ No ____

Signature of injured party

x____________________________________________________________________________

Date

*No medical attention was desired and/or required:

Signature of injured party if medical attention declined Date

Name of person filling out report ____________________________________________

Signature

x____________________________________________________________________________

Date

Name of farm owner/manager ____________________________________________

Signature

x____________________________________________________________________________

Date