Employee's Report of Accident (Ultimate Print Source)
Please submit right away while details are fresh in your mind and no later than 12 hours after an accident has occurred, no matter how major or minor the accident.
Email address *
Employees Name *
Your answer
Job Title
Your answer
Exact Date/Time of Injury *
Your answer
Plant location where injury occurred *
Your answer
Name of person to whom this incident was reported
Your answer
Name of witnesses
Your answer
Summarize what you think happened
Your answer
Select One
If re-injury, when and where was previous injury?
Your answer
Who was employer at time of original injury:
Your answer
What was claim number of original injury?
Your answer
Would you be willing to perform light-duty work during your recovery if available?
Date and time you sought medical attention
Your answer
Whom did you see
Your answer
Office/Hospital Name
Your answer
Office/Hospital Name
Your answer
A copy of your responses will be emailed to the address you provided.
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