Accident Report Form

Accident Report Form
Any staff member may fill out an accident report form as needed. If an employee is injured, have the report submitted by the most senior team member on staff or an immediate supervisor. Always contact HR or a Manager no matter the hour. Provide 818-626-2102 as a contact number.
Manager or Staff Reporting

First NameLast Name
Date of Report

MonthDayYear
Date
Injured Person

First NameMiddle NameLast Name
Time of Injury

:HourMinutesAM/PM Option
Date of Injury

MonthDayYear
Date
Injured Party Affiliation

EmployeeNon EmployeeOther
Injured Party Phone

Area CodePhone Number
Name of location if available
Location of injury

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Nature of injury
Details of incident
Was an incident report filed

YesNoOther
Was emergency services required

Yes, EMS arrived for a field evaluationYes, Injured person self transportedYes, EMS transportation requiredNo, Injured person refused transport or medical evaluationNo, medical services were not needed and / or requested
Did injured party seek medical attention

YesNoOther
Medical treatment provided if any
Is there documentation of injury

PhotosVideoNoOther
Has a claim number been requested and provided to employee from the company workers comp insurance.

YesNoOther
If employed, was the employee issued a Workers Comp Form
Relevant Insurance Claim number
Was police action needed

YesNo
Police Report Number
Was an arrest made in connection to incident

YesNoOther
Details of Police response
Was management notified

YesNo
Was employee able to finish scheduled shift

YesNoOther
Contact info for all witnesses
Submit all photos and video, and additional supporting evidence to the report email. Contact office once all accident reports are completed. An incident report must be filled out with all accident reports.

HR will request a claim number if needed prior to completion of this form. An incident report must be filled out in order to recieve a claim number.
Should be Empty: