Employee Accident Report Form
Date
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Month
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Day
Year
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Employee Name
*
First Name
Last Name
Employee's Manager's Name
*
First Name
Last Name
Incident Date and Time
*
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Month
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Day
Year
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Location
*
Description of Incident
*
Employee Explanation/Notes/Statement
*
Ask the employee to describe what happened during the incident. Allow the employee to explain what happened before asking questions. Questions should be used to fill in any gaps from the employee's statement. Who was involved? What type of accident was it? What were the injuries? Was there any damage? What manager was notified? Were there any immediate hazards after the incident? Has the hazard been removed?
Witness/Witnesses
*
Signature
*
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