Employee Report Of Accident/injury
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EMPLOYEE REPORT of ACCIDENT/INJURY
The employee must complete this report as soon as possible following an accident/injury. This report will be provided to the supervisor within 24 hours of the
accident/injury.
Name:
Date of Injury:
Time of Injury:
AM PM
Social Security #
Date of Birth:
Work Phone #
Home Phone #
Full Time
Part Time
Date Employed:
Dept/Div:
Home Address:
Shift:
A
B
C
Start Time of Work Day:
: AM PM
Witnesses (attach statement for each)
Name:
Title:
Phone Number:
Name:
Title:
Phone Number:
Name:
Title:
Phone Number:
Exact Location Injury Occurred:
Duties Being Performed:
Describe the circumstances causing the injury:
Personal Protection Equipment Used:
Foot Protection.
Face/Eye Protection.
Fall Protection.
Respiratory Protection.
Hand Protection.
Head Prot.
Apron/Chaps
Back Belt
None
Lifting Assistance Device
Other:
Object, equipment, or substance, which caused injury:
Choose factor (s), which directly or indirectly caused the accident to occur:
Struck by Flying/Thrown Object
Caught in/Under/Between Objects
Temperature Extremes
A Fall
Struck by an Object/Person
Rubbed or Abraded by Object
Bodily Reaction
Electric Shock
Struck Against Object
Blood/Fluid Exposure
Other Disease Exposure
Noise Exposure
Vehicle/Equipment Accident
Toxic Material Exposure
Repetitive Motion
Other-Describe
Client Caused
Client Assault
Nature of Injury:
Head
Trunk
Digestive
Eye (s) R L B
Wrist(s) R L B
Ankle(S) R L B
Neck
Abdomen
Respiratory
Shoulder(s) R L B
Finger(s) T I M R P
Foot/Feet R L B
Chest
Groin
Circulatory
Arm (s) R L B
Hip(s) R L B
Toe(s) R L B
Back
Skin
Hand (s) R L B
Other-Describe:
Medical Treatment:
No Treatment
First Aid
Employee Health Clinic
Outside Medical Treatment
Employee’s Signature:
Title:
Date:
Supervisor’s Signature:
Title:
Date:
Distribution:
DHHS S&B Form 3010 E (06/30/09)
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Parent category: Business