EMPLOYEE ACCIDENT REPORT

EMPLOYEE ACCIDENT REPORT

Mitchell County Animals Rescue, INC. Please fill out this form to the best of your ability.
Location of injury:
Event
Other - please note address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Injured of III Employee:
Name
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Date of birth

MonthDayYear
Date
Current age
Soc. Security Number:
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Job position / title
Incident Description:
Specific location of accident or injury (yard, lab, cat room, etc)
What was the employee doing when injured? (be specific)
How did the accident occur?
Describe the injury or illness in detail and indicate the part of the body affected.
Name the object of substance which directly injured the employee
Date of injury or initial diagnosis of occupational illness

MonthDayYear
Date
Medical care: Medical care is always recommended by employer Mitchell County Animal Rescue, Inc.
Does employee want medical care
Signature
Name and Address of Physician:
Report Date

MonthDayYear
Date
Received by:
Should be Empty:

Injured of III Employee: