Company Name
Q.A. Department
Incident/Accident Report

Revision No.:
Issue Date:

Name of injured Person _______________________________________________ Age: _____________
Department:___________________  Gender: __________________ Blood Group:__________________
Area: __________________________________________________ Phone: _______________________
Date of Accident: _________________________ Time of Accident: ______________ _________AM/PM
Place of Accident: ________________________   Part of Body Injured ___________________________
Description of Injury: ___________________________________________________________________

                Was First Aid Given?                 Yes              No                By Whom (Name): __________________

                     Body fluid Spilled:                  Yes              No

        What type of first aid given? __________________________________________________
Was removed from accident scene by?                   Ambulance / Private / Police / Other
Describe how injury of illness occurred:  ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­___________________________________________________

Probable length of disability.                                             Has employee returned?          YES                  NO
(If hospitalized):
  Physician:- _______________________      Name & Address: ________________________________
  Hospital:- ________________________      Name & Address: ________________________________
            Whether recommended for Rest        YES          NO                 If Yes for how many days:
                                             Name                     Designation               Sign
Incident reported By :       _______________     _____________    ____________
               Verified By:       _______________     _____________    ____________

  Rehabilitation Verification :(To be filled by QA Department)
      Employee returned on duty on : ____________
      Found fit for job                    YES         NO
 Sign of Employee: ____________________________ Date: _________________________ 
Remarks: __________________________________________________________________________

 Checked By                                         Verified By                                       Approved By:
 QA Manager                                       Admin Manager                                     Director
Prepared By:

QA Officer
Reviewed By:

QA Manager
Authorized By: