Employee Info
MM slash DD slash YYYY
Supervisor Information
Witness Information
Do you require medical attention
MM slash DD slash YYYY
Accident Witness Statement
Witness Supervisor Information
MM slash DD slash YYYY
Supervisor's Accident Statement Injured Person Info
Are they an employee
Accident Info
MM slash DD slash YYYY
Employer's Premises?
Job Site?
Property Info
Any prior physical conditions
Please indicate all of the following which contributed to the injury or illness *
Was employee trained in the appropriate use of personal protective equipment/proper safety procedures?
Was employee cautioned for failure to use personal protective equipment / proper safety procedures?
Did employee promptly report the injury/illness?
Is there modified duty available?
MM slash DD slash YYYY