Employee Accident/Injury Report

Injured Person
Name *
Name
Birthdate *
Birthdate
Phone *
Phone
Time and Location of the Accident/Injury
Date *
Date
Nature and Cause of the Accident/Injury
Did anyone see you get hurt? *
Did you report this incident to anyone? *
Date you reported incident
Date you reported incident
Nature of the Accident/Injury
Action Taken
Was first aid provided? *
Was other Medical Treatment sought? *
Is this an aggravation of a previous injury? *