Employee Accident Report Form

Complete this form:

Complete this form
1.
*

Name:

2.
*

Today's Date:

3.
*

Home Phone:

4.
*

Occupation

5.
*

Supervisor:

6.
*

Date of Injury:

7.
*

Time of Injury:

8.
*

Describe Specific Injury:

9.
*

Part of Body Affected:

Location (address) where event occurred

10.
*

Address:

11.
*

City:

12.
*

State and Zipcode:

13.
*

Equipment, Materials or Chemicals being used when the event occurred:

14.
*

Area where event occurred (e.g. Classroom, Hall, Parking Lot):

15.
*

Specific Activity being performed when the event occurred:

16.
*

Name of any witnesses:

17.
*

Were you treated in an Emergency Room or Clinic:

(1 required)
Yes
  No
18.

If yes, where (Hospital/Clinic name, address and phone):

19.
*

Did you miss and work days:

(1 required)
Yes
  No
20.

If yes, last day worked:

21.

Date Returned to Work:

Usual Work Schedule

22.
*

Start Time:

23.
*

Hours per Day:

24.
*

Hours Per Week:

25.
*

Days per Week:

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