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Employee's Report of Accident

  1. Please type your full name here.

  2. Make sure you protect this information.

  3. Use this space to give as much description as possible about how your injury occurred.

  4. Did your injury occur from one specific incident?

  5. Is there any way, other than described above, that you could have possibly injured yourself?

  6. (e.g. what caused you to fall)

  7. Make sure to include the approximate weight of the object.

  8. (e.g. sitting, standing, squatting, bending)

  9. (i.e. names/addresses for any witnesses)

  10. Please sign and date it this once your print this form.

  11. Supervisor must sign and date once the form is printed.

  12. REPORT ALL ACCIDENTS, REGARDLESS OF SEVERITY. THIS REPORT MUST BE SUBMITTED NO LATER THAN 24 HOURS AFTER THE ACCIDENT.

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