Employee Accident Report Form

Employee's Mailing Address

Incident Date and Time

Month Day Year
at
Hour Minutes AM/PM Option Date Picker Icon
Time employee began work on the date of injury

: Hour Minutes AM/PM Option
If there is lost time, what was the last day employee worked

Month Day Year Date Picker Icon
Location of Accident/Incident
What was the employee doing when the accident occurred?
How did the accident occur?
What was the injury or illness? List the part of body affected and explain how it was affected.
What object or substance, if any, directly harmed the employee?
Name and address of physician/health care professional:
If treatment was given away from the work site, list the name and address of the place it was given.
Was the employee treated in an emergency room?

Yes No
Was the employee hospitalized overnight as an inpatient?

Yes No
Witness/Witnesses
Phone Number

Area Code Phone Number
Should be Empty:

Greenville University