Employee Accident/Injury Report

Injured Employee Data*

Employee Name*

Employee Current Address*

Social Security Number*

Work Location*

Department / Unit / Position / Title*

Date of Birth*

Date of Injury*

Date of Hire*

Time of Injury*

:

Shift Start Time*

:

Shift End Time*

:

Injury Witnessed?*

Yes
No

Employee Primary Phone

Work Phone*

Other/Cell*

Employee Email*

Name & Title of Witness

Witness Phone

Witness Email

*Attach written witness statement to this form

Max. file size: 4 GB.

Supervisor on Duty

Supervisor Phone

Supervisor Email

Injury & Treatment Information

Injury & Treatment Information:

No Injury / Report Only

Body Part Injured:

Nature of Injury:

Cause of Injury:

Location of Injury:

Comments:

Personal Protection Equipment Available?

Yes
No

Personal Protection Equipment Utilized

Gloves
Mask/Respirator
Gown
Lifting Assistance Device
Other

Medical Treatment

No Treatment
First Aid
On Site Employee Health Clinic
Urgent Care
Other

Treatment Received at

Facility Phone

Name & Title of Treating Provider

Accident / Incident / Injury Description (attach additional pages if necessary)

Instructions: Describe in detail what happened? What caused the accident? What were the contributing factors? Reconstruct the sequence of events that led to the injury. Attach additional sheets if necessary. This document becomes an official accounting of the facts surrounding the accident. When documenting the facts, include answers to the following questions:

1. Where did the accident happen and who was involved? Provide a full description of the surroundings of the location and the individuals involved.

2. What was happening at the time of the accident and why was it taking place?

3. What were the events leading up to the accident? Describe the sequence in order and when they took place.

4. . What exactly caused the injury and how did it happen? What were the mechanics (body movement / position), equipment or tools involved?

5. Describe the injury or injuries incurred. What body part and what kind of injury? (Indicate if no injury occurred.)

Accident Findings

After review of all facts, what was the hazardous condition, unsafe work practice, or other causal factors (procedure, equipment, people, and environment) that contributed to the accident / injury?