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Accident Report Form

The accident report form records a workplace accident in which a person was injured, so the employer can arrange treatment, notify authorities and insurers, process ESI or employee compensation claims and prevent recurrence. HR or the safety officer completes it with the supervisor soon after the accident.

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[Company Logo][Company Name]

ACCIDENT REPORT FORM

Report No.:: [Reference Number]
Establishment:: [Company Name], [Work Location]
Date of Report:: [Date]

A. Injured Person

Name
Employee ID / Contractor Name
Designation
Department
Age
Gender
UAN
ESI IP Number (if covered)
Contact Number
Emergency Contact informed (name, time)

B. Accident Details

Date of accident [DD/MM/YYYY]
Time
Shift and hours worked before accident
Exact place
Activity being performed
Machine / tool / vehicle involved
How the accident happened
PPE being worn at the time

C. Injury Details

Body Part	Nature of Injury	Severity
[Hand / Leg / Head / Eye / Back / Other]	[Cut / Fracture / Burn / Sprain / Other]	[Minor / Serious / Fatal]
[Body Part]	[Nature]	[Severity]

D. Treatment

First aid given by
Taken to (hospital / ESI dispensary / clinic)
Doctor's name
Admitted? (Yes / No)
Expected days off work
Date resumed duty

E. Witnesses

Name	Employee ID	Contact	Statement Attached
[Witness Name]	[Employee ID]	[Phone]	[Yes / No]
[Witness Name]	[Employee ID]	[Phone]	[Yes / No]

F. Notifications and Claims

Notification / Claim	Required?	Date Sent	Reference
Statutory accident notice to authority	[Yes / No]	[DD/MM/YYYY]	[Reference Number]
ESIC accident report	[Yes / No]	[DD/MM/YYYY]	[Reference Number]
Insurance / employee compensation claim	[Yes / No]	[DD/MM/YYYY]	[Reference Number]
Principal employer / contractor informed	[Yes / No]	[DD/MM/YYYY]	[Reference Number]

G. Supervisor's Account and Immediate Action

Supervisor's account
Immediate corrective action
Incident investigation form no.

Declaration

The above information is true and correct to the best of my knowledge. Medical documents are attached and will be kept confidential.

Injured Person (when able)
[Employee Name]
Date: [Date]

Supervisor
[Name]
Date: [Date]

HR / Safety Officer
[HR Name]
Date: [Date]

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What this template includes

Injured person's details including UAN / ESI number
Accident particulars: time, place, activity, machine
Body part and nature of injury
Treatment given and hospital details
ESI, insurance or employee compensation follow-up
Statutory notification tracking
Witness details and supervisor's account

When to use it

A worker is injured by a machine, tool, vehicle or fall
An employee is injured while travelling on official duty
A contract worker is hurt at your site
An injury needs hospital treatment or leads to absence from work

How to customise this template

1Pre-fill company, unit and ESI code details
2Add your insurer and policy number for non-ESI employees
3Fill in the notification steps applicable in your state
4Attach the incident investigation form for root cause
5Store with the medical documents in a confidential file

HR tips

Get the injured person to hospital first; complete the form after
Record the employee's own account when they are able to give it
Do not record speculation about fault in the factual section
Track days lost to work for safety statistics

Accident notices, ESI accident reports and compensation obligations are governed by the OSH Code, 2020, the Code on Social Security, 2020 and state rules (in force from 21 November 2025, with rules being notified); verify current forms and deadlines.

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Frequently asked questions

Is it mandatory to report a workplace accident?+

Accidents causing death or certain bodily injury and dangerous occurrences must be notified to authorities under applicable laws. ESI-covered employees' accidents must also be reported to ESIC. Check current rules.

Who pays for treatment of an injured employee?+

For ESI-covered employees, ESI provides medical and disablement benefits. For others, the employer's liability for compensation and any insurance policy apply.

What should an accident report contain?+

Who was injured, when, where and how, nature of injury, treatment given, witnesses and immediate action. This form covers each of these.

All 50 posh, workplace safety & compliance →

[Company Logo][Company Name]
COMPLAINT OF SEXUAL HARASSMENT AT THE WORKPLACE
To,
The Presiding Officer
Internal Committee, [Company Name]
[Company Address]
Email: [IC Email Address]

This form is confidential. You may attach additional sheets wherever space is insufficient.
Part A – Complainant Details
Full Name
Employee ID / Contractor / Visitor
Designation
Department
Work Location
Preferred Contact Number
Preferred Email
Best time and way to contact you
Part B – Respondent Details
Name of Respondent
Designation
Department / Organisation
Work Location
Relationship to you (manager, colleague, client, vendor, other)
Part C – Details of the Incident(s)
Form · Word
POSH Complaint Form
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[Company Logo][Company Name]
INQUIRY REPORT OF THE INTERNAL COMMITTEE
Complaint Ref. No.:
[Reference Number]
Complainant:
[Complainant Name], [Designation]
Respondent:
[Respondent Name], [Designation]
Date of Complaint:
[DD/MM/YYYY]
Date of Report:
[Date]
Classification:
Strictly Confidential
1. Committee Members Who Conducted the Inquiry
Name Role Sittings Attended
[Member Name] Presiding Officer [Number]
[Member Name] Member [Number]
[Member Name] Member [Number]
[Member Name] External Member [Number]
2. Summary of the Complaint
The complainant alleged that [brief factual summary of each allegation, with dates and places]. The complainant sought [relief requested].
3. Reply of the Respondent
Report · Word
POSH Investigation Report
Download .docx

Full Name
Employee ID / Contractor / Visitor
Designation
Department
Work Location
Preferred Contact Number
Preferred Email
Best time and way to contact you

Name of Respondent
Designation
Department / Organisation
Work Location
Relationship to you (manager, colleague, client, vendor, other)

Name	Role	Sittings Attended
[Member Name]	Presiding Officer	[Number]
[Member Name]	Member	[Number]
[Member Name]	Member	[Number]
[Member Name]	External Member	[Number]

[Company Logo][Company Name]

ANNUAL REPORT OF THE INTERNAL COMMITTEE

Reporting Period:: [DD/MM/YYYY] to [DD/MM/YYYY]
Date of Report:: [Date]
Submitted To:: The Employer and the District Officer, [District Name]

1. Establishment Details

Name of Organisation	[Company Name]
Address	[Company Address]
Nature of business
Total employees (Men / Women / Others)
Locations covered by this report

2. Composition of the Internal Committee

Name	Role	Gender	Appointed On	Remarks (changes during year)
[Member Name]	Presiding Officer	Female	[DD/MM/YYYY]	[Remarks]
[Member Name]	Member	[Gender]	[DD/MM/YYYY]	[Remarks]
[Member Name]	Member	[Gender]	[DD/MM/YYYY]	[Remarks]
[Member Name]	External Member	[Gender]	[DD/MM/YYYY]	[Remarks]

3. Complaints Summary

Report · Word

POSH Annual Report Format

Download .docx

[Company Logo][Company Name]
POSH TRAINING FEEDBACK FORM
Session Date:
[DD/MM/YYYY]
Trainer:
[Trainer Name]
Batch / Location:
[Work Location]
Your feedback helps us improve. Writing your name is optional. Please do not use this form to report a complaint; contact the Internal Committee at [IC Email Address] or any committee member instead.
Section A – About You (optional)
Name (optional)
Department
Role level (Staff / Supervisor / Manager)
Employee or contract staff
Section B – Rate the Session (1 = Poor, 5 = Excellent)
Aspect 1 2 3 4 5
Content was clear and easy to understand
Examples were relevant to our workplace
Trainer handled questions well
Duration was appropriate
Language of delivery suited me
Form · Word
POSH Training Feedback Form
Download .docx
[Company Logo][Company Name]
WORKPLACE SAFETY INCIDENT REPORT
Incident No.:
[Reference Number]
Date of Report:
[Date]
Reported by:
[Employee Name], [Designation]
Part 1 – Incident Details
Date of incident [DD/MM/YYYY]
Time
Shift
Location / area / machine
Department
- Fire / smoke / explosion
- Electrical incident
- Chemical / gas / oil leak or spill
- Equipment, vehicle or machine failure
- Structural failure / falling object
- Injury to person (attach injury report)
- Property damage only
- Other: [Details]
Description: what happened, in sequence
Persons involved (name, ID, employee / contractor / visitor)
Witnesses (name, contact)
Part 2 – Immediate Action
Form · Word
Workplace Safety Incident Form
Download .docx

Name (optional)
Department
Role level (Staff / Supervisor / Manager)
Employee or contract staff

Date of incident [DD/MM/YYYY]
Time
Shift
Location / area / machine
Department

Description: what happened, in sequence
Persons involved (name, ID, employee / contractor / visitor)
Witnesses (name, contact)

[Company Logo][Company Name]

EMPLOYEE INJURY REPORT

Report No.:: [Reference Number]
Date Submitted:: [Date]

1. Employee Details

Employee Name
Employee ID
Designation
Department
Reporting Manager
Work Location / Work from Home
ESI IP Number (if applicable)

2. Your Account of the Injury

Date and time of injury or when symptoms started
Where were you and what task were you doing?
Describe how it happened in your own words
Was it a sudden event or gradual (over days or weeks)?
Body part affected and symptoms
Did anyone see it happen? Names

3. Reporting

Report · Word

Employee Injury Report

Download .docx

[Company Logo][Company Name]
NEAR-MISS REPORT
Report No.:
[Reference Number]
Date:
[DD/MM/YYYY]
Time:
[Time]
Location / Section:
[Work Location]
Reported By (optional)
Name
Employee ID / Contractor Name
Department
Prefer to stay anonymous (Yes / No)
What Did You See?
- Unsafe condition (broken guard, spill, exposed wire, blocked exit)
- Unsafe act (no PPE, shortcut, bypassing safety device)
- Equipment / vehicle near-miss
- Falling or flying object
- Electrical / fire near-miss
- Other: [Details]
Describe what happened or what you saw
What could have happened?
Was anyone at risk? How many people?
Form · Word
Near-Miss Incident Report
Download .docx
[Company Logo][Company Name]
FIRST AID INCIDENT FORM
Form No.:
[Reference Number]
Date:
[DD/MM/YYYY]
Time:
[Time]
Location:
[Work Location]
Person Treated
Name
Employee ID / Visitor / Contractor
Department / Company
Age
Contact Number
Complaint or Injury
- Cut / abrasion
- Burn
- Sprain / strain
- Eye irritation / foreign body
- Fainting / dizziness
- Headache / fever
- Allergic reaction / insect bite
- Other: [Details]
Brief description of what happened
Work-related? (Yes / No)
Body part affected
Form · Word
First Aid Incident Form
Download .docx

Aspect	1	2	3	4	5
Content was clear and easy to understand
Examples were relevant to our workplace
Trainer handled questions well
Duration was appropriate
Language of delivery suited me

Describe what happened or what you saw
What could have happened?
Was anyone at risk? How many people?

Name
Employee ID / Visitor / Contractor
Department / Company
Age
Contact Number

Brief description of what happened
Work-related? (Yes / No)
Body part affected

Accident Report Form

Preview of the form

A. Injured Person

B. Accident Details

C. Injury Details

D. Treatment

E. Witnesses

F. Notifications and Claims

G. Supervisor's Account and Immediate Action

Declaration

What this template includes

When to use it

How to customise this template

HR tips

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Frequently asked questions

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