Jenks Public Schools Accident Report
Every accident should be investigated and the causes corrected so that more accidents will not occur. Do not
overlook the so-called “unimportant” cases, because, except for “chance,” they could also have been serious. It is
only by thorough investigation that many of the real causes can be determined and corrected.
Name of Employee
Job Title/Site
Date of Accident
Time
Time shift begins
Did employee lose time from work? Choose One Hours lost on date of accident
Has employee returned to work? Choose One
Service with the company:
years. In present job:
years.
Give us your honest comments on questions below. It is not our intent to blame anyone;
however, your opinion may help us to prevent areas of repetition.
Please answer the following:
1. Was injured person properly instructed in safe and efficient method(s) ..............
2. Did injured person violate any instructions? ........................................................
3. Was necessary protective equipment worn? ........................................................
4. Did poor housekeeping contribute to accident? ...................................................
5. Did horseplay cause the accident? ......................................................................
6. Was the accident caused by something which needed repairs? ...........................
7. Should a guard be provided? ................................................................................
8. Did any bodily defect contribute to the accident? ................................................
9. Was the accident caused by an unsafe act? ..........................................................
10. Did the injured party report the injury to the supervisor immediately?................
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
N/A
Accident – Describe what the injured party was doing at time of accident, what happened, who was involved,
nature of injury, part of body affected ___________________________________________________.
Number of employees at work site
Witnesses’ name(s)
Unsafe Act – What (if anything), did the employee or another person do incorrectly?_____________
Unsafe Conditions – What unguarded or unsafe condition of machinery, equipment, building or premises was
involved?
Remedy – What should be done to correct the conditions which caused this accident?
Action Taken – What has been done to correct the conditions which caused this accident?
Medical Care – Did employee go to doctor or hospital? Yes
No
If yes, complete the following:
Name of doctor or hospital
Date of initial visit
Address
Telephone Number
Report submitted by injured party. Date:
Employee Signature:
Report prepared by:
Date:
Administrator’s Signature:
Date:
As Administrator, do you feel that this injury should be covered under worker’s compensation benefits?
Yes
No Reason(s) why