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Employee Accident Investigation Form
Seeking Medical Treatment
Injured Employee Information:
Employee Name
*
First Name
Last Name
Property/Department
*
Position Title
*
Date of Birth
SSN
Gender
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Accident Information
Date of Accident
*
-
Month
-
Day
Year
Date
Time of Accident
*
Date Reported
*
Name of any Witness(es)
Witness phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Witness Email
example@example.com
Was employee working at the time of the accident?
*
Location of Accident
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Severity of Injury
*
High
Medium
Low
Type of Injury (Check all that apply)
*
Contusion/Crush
Burn
Dislocation
Slip
Laceration
Concussion
Sprain/Strain
Fall
Other
If other please explain
Location of Injury (Please Check All That Apply)
*
Head/Face
Eye
Internal Organs
Back
Hand/Fingers
Shoulder/Arm
Legs
Foot
Other
If other please explain
Please provide a full written statement of how the accident happened:
*
Were there any contributing factors that caused the injury:
*
What could be done to prevent future accidents:
*
Printed Name of Supervisor Completing Form
*
First Name
Last Name
Signature of Supervisor
*
Date
-
Month
-
Day
Year
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Submit
Submit
Should be Empty: