Front of the fine arts building during a sunny morning on the right with some of the green on the left.
Location: Building 832B
Room 1013
Phone: (904) 620-2019
Fax: (904) 620-2025

Accident Report

Please use this form to report accidents and then press 'Submit'. If you have any difficulties submitting this form, please print and send to Dan Endicott, Bldg 832B Room 1013.

Department:
Date:
Name of Injured:


Time of Accident:
 Employee Job Title:
Length of Experience on Job:
 Location where Accident Occurred:
Nature of Injury type, and part of the body affected:
Describe the accident and how it occurred:
Describe the accident, including exactly what happened and where and how it happened. Describe the equipment or materials involved.
Cause of the accident:
Describe all the conditions or acts which contributed to the accident, e.g.
a. unsafe conditions - spills, grease on floor, poor housekeeping or other physical condition.
b. unsafe acts - unsafe work practices such as failure to warn, failure to use required personal protective equipment.
Was personal protective equipment required?
Witness(es): List name(s), address(es) and phone number(s):
Safety training provided to the injured?
Was any safety training provided to the injured related to the work activity being performed? If "no", explain:
Interim corrective measure taken to prevent reccurence:
Permanent corrective measures recommended to prevent recurrence:
Prepared by:
Status and follow-up action taken by safety coordinator:
Once the investigation is complete, EH&S shall review and follow-up the investigation to ensure that corrective actions are taken and control measures have been implemented.