Employee Accident Report

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EMPLOYEE ACCIDENT REPORT
EMPLOYEE INFORMATION
ACCIDENT INFORMATION
NAME
DATE
AGE
TIME
SS #
LOCATION
POSITION
WITNESS
DESCRIBE WHAT HAPPENED IN DETAIL INCLUDING TIMES AND LOCATIONS
DESCRIBE ALL INJURIES IN DETAIL INCLUDING ANY PART OF THE BODY EFFECTED
NAME AND ADDRESS OF PHYSICIAN
IF APPLICABLE, NAME & ADDRESS OF HOSPITAL
COMMENTS FROM WITNESSES
OTHER COMMENTS
WORK STATUS
Did the employee return to work
YES
NO
If no, when was the day and time at work
EMPLOYEE
SIGNATURE
DATE
SUPERVISOR
SIGNATURE
DATE
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