USD 358 Employee Accident Report

Date of accident

Employee Involved

First NameLast Name

Job Title:

Place where accident occurred (be specific)

Descibe accident in your own words:

Report completed by:

First NameLast Name

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To be completed by school nurse, if available:

Injury to employee:

Was employee transferred for further medical treatment?

YesNo

If so, where?

Any follow-up required or did any follow-up take place?