ACCIDENT REPORT
NAME
DATE OF THIS REPORT
/
Month
/
Day
Year
Date
BIRTHDAY
SOCIAL SECURITY
ADDRESS
PHONE NUMBER
Format: (000) 000-0000.
DATETIME OF ACCIDENT
/
Month
/
Day
Year
Date
EMAIL
example@example.com
WHAT PART OF YOUR BODY IS INJURED?
WHICH SIDE OF YOUR BODY?
Left
Right
Center
Bottom
Top
WHERE DID THE ACCIDENT OCCUR? (EX. ONSTAGE, OFFSTAGE, IN THE DRESSING ROOM, IN THE HALLWAY ETC)
PLEASE DESCRIBE HOW THE ACCIDENT OCCURRED.
WAS THERE AN OBJECT OR SUBSTANCE THAT DIRECTLY AFFECTED YOU?
WILL YOU SEEK MEDICAL ATTENTION?
YES
NO
NOT YET
DATE (of Dr. Appt)
/
Month
/
Day
Year
Date
HAVE YOU MADE A DOCTOR'S APPOINTMENT?
YES
NO
NOT YET
DOCTORS NAME
PLEASE NOTIFY STAGE AND COMPANY MANAGEMENT OFFICE WHEN YOU SEE A DOCTOR so THAT THE PROPER PAPERWORK CAN BE COMPLETED.
__________________________________________________
Company Management Section (DO NOT FILL OUT)
C2 Filed on
Date of Hire
/
Month
/
Day
Year
Date
Claim Number
Current Salary
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