The unsafe acts of persons and the unsafe conditions that cause accidents can be corrected only when they are specifically known. You are responsible for immediately reporting unsafe working conditions and/or unsafe persons in the work area. General Information Name of injured: ______________________________________________________ Dept.: ______________________________________________________ Date of accident: _______________________        Time: ________         A.M.   P.M. Location of accident  ______________________________________________________ Job or activity at time of accident: ____________________________________________ Accident Description Describe the Accident: _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ Names of witnesses: _______________________________________________________________________________________________________ Cause of the Accident Describe any unsafe actions: _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ Describe any unsafe conditions: _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ Describe any contributing causes: _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ Corrective Action to be Taken: Recommend what can be done and by whom to prevent the recurrence of a similar accident. _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ Supervisor […]