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Employee Accident/Injury Report
Name of Injured Person
Mailing Address
Birthdate
Phone
Date of Injury
Time of Injury
Weather Conditions
Location
Describe how the accident/injury occurred (Be VERY specific – include any equipment, materials, or chemicals being used).
Did anyone see you get hurt?
Yes
No
If yes, who?
Did you report the incident to anyone?
Yes
No
If no, why not?
If yes, to whom did you report it?
Date you reported the incident
What part(s) of your body was/were affected? (Be Specific – for example, right elbow, left knee)
What type of injury did you experience? (Be Specific – for example, bruise, scrape, cut, pull)
Was first aid provided?
Yes
No
If yes, please describe
Was other Medical Treatment sought?
Yes
No
If yes, when?
Where?
If not immediately, why not?
Is this an aggravation of a previous injury?
Yes
No
If yes, when were you last treated for the previous injury?
Submit Form
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