A NEW MUSICAL WANTED THE LEGEND OF THE SISTERS CLARKE
ACCIDENT REPORT
NAME
DATE OF THIS REPORT
/
Month
/
Day
Year
Date
BIRTHDAY
SOCIAL SECURITY
ADDRESS
PHONE NUMBER
Format: (000) 000-0000.
DATE/TIME 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
Top
Bottom
WHERE DID THE ACCIDENT OCCUR? (EXAMPLE ON STAGE, OFF STAGE, IN THE DRESSING ROOM, IN THE HALLWAY ETC.
PLEASE DESCRIBE HOW THE ACCIDENT OCCURRED
WAS THERE AN OBJECT OR SUBSTANCE THAT DIRECTRLY AFFECTED YOU?
WILL/DID YOU SEEK MEDICAL ATTENTION?
YES
NO
NOT YET
Date
-
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)
Preview PDF
Submit
Should be Empty: