LFX Injury / Accident Report
Please fill out all details below.
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name
*
First Name
Last Name
What Division do you work in?
*
What is your position?
*
What is the location where injury/accident occurred?
*
Injury or Accident?
*
Please Select
Injury
Accident
Nature of Injury
(ex. arm, leg, back, etc.)
Date & Time of Injury
First Aid Provided?
Please Select
Yes
No
If yes, who provided First Aid?
Hospital or Clinic Attended?
Please Select
Yes
No
Name of individual who transported team member if applicable
Is this a lost time injury?
Please Select
Yes
No
Was any individual who DOES NOT work for LFX involved?
Please Select
Yes
No
Was the MOL called?
Please Select
Yes
No
Please describe what happened.
Include details of equipment or materials used.
Were there any witnesses?
Please Select
Yes
No
Please name witnesses with their contact information.
Please upload photo(s) of injury/accident.
*
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