Employee Accident Form
NOTE: All Employee Accidents must be reported to Incident Hotline immediately 614-701-6993 and reports must be completed within 24 hours. Workers Compensation certification may be questioned on accidents reported after 24 hours.
Employee Name
*
First Name
Last Name
Date of Accident:
*
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Month
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Day
Year
Date
Time of accident:
*
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Hour
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Minutes
AM
PM
AM/PM Option
Job title/position:
*
Scheduled Work Department:
*
Park West
Supported Community Living
Johnstown
Open Door
UCO
CAC
Corporate admin/support
If ICF or SCL, List specific name of home or apartment. If Day Service/transportation, list room or specific location where accident occurred:
*
List names of any witnesses:
*
Detailed description of accident and injury: (include what you were doing at time of accident. If lifting, give size, weight and distance lifted. Describe part of the body injured and nature of injury, for example, first joint of left index finger, etc...)
*
Employee email
*
example@example.com
Submit
Should be Empty: