Greenville University
Employee Accident Report - First Report of Injury
Current Date
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Month
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Day
Year
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Employee's Full Name
First Name
Last Name
Birthdate
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Month
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Day
Year
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Employee's Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employee's E-mail Address
@greenville.edu
Employee's Daytime Phone Number
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Area Code
Phone Number
Gender
Male
Female
Marital Status
Married
Single
Number of dependents
Avg Weekly Wage
Job Title or occupation
Date Hired
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Month
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Day
Year
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Incident Date and Time
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Hour
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Minutes
AM
PM
AM/PM Option
Time employee began work on the date of injury
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Hour
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10
20
30
40
50
Minutes
AM
PM
AM/PM Option
If there is lost time, what was the last day employee worked
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Month
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Day
Year
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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
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Area Code
Phone Number
Submit
Should be Empty: