WORK-RELATED ACCIDENT / INJURY

REPORT FORM

INSTRUCTIONS	CLAIM NO.
This form shall be completed as soon as possible following an employee-related accident or injury. If the employee is unable, the supervisor shall complete this form, and then submit it to the Human Resources office.

PERSONAL INFORMATION

EMPLOYEE NAME	SOCIAL SECURITY NO.	EMPLOYEE ID	TODAYS DATE
JOB TITLE	DATE OF HIRE	RATE OF PAY
HOME ADDRESS	HOME PHONE	WORK PHONE
SUPERVISOR NAME	SUPERVISOR EMAIL	PHONE
EMPLOYEE STATUS	HOURS PER DAY	DAYS PER WEEK
FULL-TIME	PART-TIME

INJURY / ACCIDENT INFORMATION

LOCATION OF INJURY	DATE OF INJURY	TIME OF INJURY
DID THE INJURY CAUSE LOSS OF TIME FROM WORK? Provide dates, amount of time	HAS THE EMPLOYEE RETURNED TO WORK?
WITNESSES Provide names of any witnesses to the accident / injury
INJURY DESCRIPTION What parts of the body were affected? What type of injury?
INCIDENT DESCRIPTION What was the employee doing at the time of the incident? How did the injury occur?

INJURY / ACCIDENT TREATMENT

FIRST AID Describe any First Aid given at the scene of the injury / accident.
WAS INJURED PARTY TREATED IN AN EMERGENCY ROOM?	WAS INJURED PARTY TAKEN BY AMBULANCE?
YES	NO	YES	NO
NAME OF TREATING DOCTOR	NAME MEDICAL PROVIDER(S)
ADDRESS	PHONE
TREATMENT RECEIVED

SIGNATURE

NAME	SIGNATURE	DATE
EMPLOYEE
- OR - SUPERVISOR

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