If you were injured at work, tell your supervisor or the person responsible for safety as soon as you can and follow your workplace reporting procedure. Use the blank accident report form below to keep your own dated account. If your employer has a form, you can use these notes to complete it. Get any urgent medical help you need first.
Blank workplace accident report form
Download the blank workplace accident report form (PDF, two A4 pages). You can also copy the questions below into your own document.
Use your own words. If you are unsure of a time or detail, mark it as approximate. Keep the completed copy privately.
1. Your name, job and employer
________________________________________________
2. When and where did it happen?
Accident date and time: ______________________________
Site and exact area, such as the loading bay or stair landing: ______________________________
3. What were you doing immediately beforehand?
Task, equipment or item you were handling: ______________________________
4. Describe what happened, in order
What you saw, felt or heard: ______________________________
What happened next: ______________________________
Anything you could not see or are unsure of: ______________________________
5. What injury or symptoms did you notice?
Part of the body affected and when you first noticed a problem: ______________________________
First aid or medical attendance, if any: ______________________________
6. Who was there?
Witness names or roles, and what each person actually saw: ______________________________
Person who came to help afterwards: ______________________________
7. Who did you tell, and when?
Name or role: ________________________ Date and time: ________________________
How you reported it and any acknowledgement or reference: ______________________________
8. What records might help?
Photographs, messages, delivery records, equipment ID, or location of a CCTV camera: ______________________________
9. What happened to your work?
When you stopped work, duties you could not perform, or lighter duties offered: ______________________________
10. When did you write this account?
Date and time: ________________________ Name: ________________________
Dated follow-up, if anything changed later: ______________________________
What should I write if I don’t know why the accident happened?
Describe what you observed. For example, “My right foot slipped beside the loading-bay door. When I stood up, I saw a patch of clear liquid on the floor. I did not see where it came from.” That records the location and condition for someone to check. If a colleague later tells you where the liquid came from, record their name and the date of that conversation separately.
Read any account written for you before signing. If an important detail is wrong, identify the sentence and ask for a correction. If the form has already been filed, send a dated correction, ask for it to be attached to the original and retain a copy. The original report and the date of the correction can both matter later.
Who sends an accident report to the Health and Safety Authority?
For a reportable accident involving an employee at work, the employer is responsible for notifying the Health and Safety Authority (HSA). The employee’s account above is for their own records. Employers who need to make a statutory notification should use the HSA’s official accident reporting guidance and reporting system.
For a non-fatal workplace injury to an employee, a report is required where the injury prevents the employee from doing their normal work for more than three consecutive days. Exclude the accident day and include days the employee would ordinarily have been off. For example, if an injury on Friday prevents someone doing their normal work from Saturday through Tuesday, that is four consecutive days. Being able to attend on lighter duties can still leave someone unable to do their normal work.
The employer must report a qualifying non-fatal injury to the HSA as soon as reasonably practicable and within ten working days of the event. Fatal accidents and specified dangerous occurrences have separate reporting rules. You can make a workplace record straight away even if you do not yet know how long your duties will be affected. Read regulations 224 and 225 on responsibility, reporting thresholds and timing.
What if my workplace has no form or I cannot get a copy?
Send a short factual account through your normal reporting channel, note who received it, and ask for acknowledgement and a copy or reference number. If no copy is available, keep your own dated record and the request you made. Where CCTV may show the incident, identify the camera location and approximate time promptly so the operator can locate and preserve the relevant footage. See the personal injury evidence guide for other records worth preserving.
Does completing the form start a claim?
No. An accident record documents what happened. A compensation claim is a separate step. If you are considering a claim, keep the report with the medical certificates, records of missed work and receipts that relate to the injury. If responsibility is disputed, details such as the equipment used, a witness’s view or the timing of a warning can help a solicitor assess what further enquiries are needed. Read how accident at work claims are assessed in Ireland.
