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An employee who is injured on the job is to notify their supervisor within 24 hours and
complete the "Report of Employee Accident" form within 10 days of the incident. |
Submit electronically to Human Resources. Print completed and signed form and give to department manager. |
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Employee Name: |
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Date of Birth |
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Age |
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Last 4 Digits of SSN
Last 4 Digits of SSN |
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Gender: |
Female
Male
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Home Address |
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Home phone |
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Employee's Occupation |
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Department: |
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Job Title: |
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On Duty?: |
Yes
No
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Date of Injury: |
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Time of Injury: |
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Date reported to employer: |
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Location of Accident: |
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Was accident or last exposure on employer's premises? |
Yes
No
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How did accident occur? |
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What was employee doing when injured? |
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Name substance or object that directly caused injury: |
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Describe in detail nature and extent of injury, indicate part of body involved: |
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Was employee admitted to hospital? |
Yes
No
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Date employee admitted to hospital if applicable: |
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Teated by emergency room only? |
Yes
No
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Hosptial name and address: |
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Name and address of attending physician or clinic: |
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Has employee returned to regular duty? |
Yes
No
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Date returned to work if applicable: |
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Light Duty? |
Yes
No
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Witnesses
Please list other employees involved or who witnessed accident. |
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Name: |
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Job Title: |
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Name: |
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Job Title: |
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Exposure Report
If incident was a result of blood or body fluid exposure, please print out Exposure forms. |
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Comments: |
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Employee Signature: |
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Date Report Done: |
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Human Resources Signature: |
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Date: |
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