Incident / Near-Miss / Accident Report

Person involved

Name

Occupation / Job Title

Address

Years Experience

Date of Birth

Incident details

Occurrence Date & Time *

Date & Time Reported *

Site Location

Incident Location

Optional — device location is only captured if you tap this.

Witness(s) Name(s):

Starting Time of Shift

Enter both times to check the 1-hour reporting requirement.

Type of event — select all that apply

Describe the Incident *

Injury / Illness

Type of Accident/Incident

Name of Medical Facility

Address of Medical Facility

Name of Treating Physician

Treating Physician Phone #

Refuses Further Treatment

Yes No

Lost time

Yes No

Drug Screen

Yes No

Part of Body Injured:

Tap the diagram where the injury is. Each tap drops a numbered marker and records the body region, the side (left / right) and the exact point. The checklist below ticks itself to match. Tap a marker again to remove it.

Injury location — front and back

No injury locations marked yet.

Checklist (auto-ticked from the diagram — adjust if needed)

Describe injury:

Signature

Near Miss

Type of Incident/Accident

Details of Potential Hazard

Type of Concern

Property Damage

Type of Incident/Accident

Causes and prevention

Completed once for this report and applied to whichever event types were selected above. In the original form this block was duplicated three times.

Conditions — check all that apply

Practices — check all that apply

What are the reasons for these practices and/or conditions?

Prevention / Corrective Action — check all that apply

Vehicle Accident

Any damaged vehicle — company-owned, rented, or leased — must be reported in this section. An employee injury report on its own is not enough to open an auto claim.

Driver

Full Name of Driver

Daytime Phone

Driver Address

Job Title

Age

Was Driver Licensed to Drive?

Yes No

Company Employee

Yes No

Driver authorized by Company:

Yes No

Notice of intended prosecution?

Yes No

Full Driver's License Information

State

Driver's License Number

Expiration

Reason for driving vehicle

Company / Rental / Leased Vehicle Details

Make

Model

Model Year

Color

Vehicle VIN — 17 characters; dashboard at the windshield or driver's door jamb

Vehicle Tag / Plate Number

Tag State

Is the vehicle

Accident Details

Vehicle being used for

Date-Time

Location

Time of Day

Weather Conditions

Condition of Road

Speed of Company Vehicle

Speed of Third Party Vehicle

Point of Impact / Damage

Tap the vehicle diagram where contact or damage occurred. Switch between the company vehicle and the third-party vehicle before marking. Tap a marker to remove it.

Damage location — top view

No damage points marked yet.

Vehicle Condition After the Accident — the insurer needs all four answers to open a claim

Is the vehicle drivable?

Yes No

Did the airbags deploy?

Yes No

Do all doors open and close properly?

Yes No

Any fluids leaking from the vehicle?

Yes No

Damage Photos

Photos of the damage must be attached before this report is submitted. If the airbags deployed, interior photos are required as well.

Photos of vehicle damage * Every damaged area up close, plus one wide shot of each vehicle and the scene.

Third Party Details

Name

Phone

Driver's Statement

Please explain fully and clearly what happened

Driver Name

Driver Signature

Evidence & reporting

Image Upload of scene — photos, multiple allowed

Name of Person Reporting *

Signature

Liquid Metal Safety Department Internal

Follow up required

Yes No

Attachment?

Yes No