Public Sector Accident

ACCIDENT/INJURY REPORTING FORM

Arkansas Occupational Safety and Health (AOSH) inspectors investigate accidents, fatalities, and complaints in compliance with state law for employees in the Public Sector.

Inspectors also work with the Public Sector by providing safety and health surveys and training.

Public Sector employers must report each injury suffered by an employee in connection with their employment on the following form:
Company Name
Company Address
Street Address Address Line 2 City State ZIP Code
Person filing report
Phone
Date of Accident
MM slash DD slash YYYY
Type of Accident
(e.g. fall, point of operation, moving equipment)
Brief description of the cause of the accident
Contributing factors in Injury
Was the employee admitted into a hospital?
- Yes
- No
Did Accident result in Fatality?
- Yes
- No
Did the company conduct an investigation of the accident?
- Yes
- No
Briefly describe what will be done or has been done to remove noted hazards.
Briefly describe what will be done to prevent this type of accident from occurring again.

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