SAMPLE INCIDENT/ACCIDENT REPORT FORM

1 - 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?

2 _____. Any photographs taken? Yes ___ No ____. Signature of injured party x_____. Date *No medical attention was desired and/or required: x 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_____. Dat