Report of Accident or Injury

Name

Job Title

Date of Birth

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Date of Hire

Date of Injury

Time of Accident

Location of Incident (be specific)

Please describe activity prior to the accident

do the of

Describe the accident

What do you believe caused the accident?

What part of your body was injured?

Have you ever injured this part of your body before?

What do you think could prevent this type of accident from occurring again??

Signature

Clear Signature

Date

Contact Information