Injury First & Last Name Email Employee Info First Last First Last Accident Information Accident Information Untitled Untitled Untitled UntitledAfghonitonSecond ChoiceThird ChoiceUntitled Time of Accident Date of Accident MM slash DD slash YYYY Describe in full how the accident occurred (including events that occurred immediately before the accident)Be specific about body part(s) affected.Reccomendation on how to prevent this accident from recurringSupervisor Information First Last Witness Information First Last Additional InformationAdditional InformationDo you require medical attention Yes No Maybe Untitled Your Signature Today's Date MM slash DD slash YYYY Accident Witness Statement First Last Email Untitled Untitled Untitled Untitled Untitled Untitled Untitled Accident InformationDescribe Bodily Injury SustainedDescribe Bodily Injury SustainedWitness Supervisor Information First Last Your Signature Today's Date MM slash DD slash YYYY Supervisor's Accident Statement Injured Person Info First Are they an employee Yes No Untitled Untitled Untitled Untitled Accident Info First Last Date of Accident MM slash DD slash YYYY Time of Accident Employer's Premises? Yes No Job Site? Yes No Property Info First First Accident Description First Accident DescriptionAccident Description First Any prior physical conditions Yes No First Accident DescriptionPlease indicate all of the following which contributed to the injury or illness * Failure to lockout Failure to secure Horseplay Improper Dress Improper guarding Improper instruction Improper maintenance Improper protective equipment Inoperative safety device Lack of training or skill Operating without authority Physical or mental impairment Poor housekeeping Poor ventilation Unsafe arrangement or process Unsafe equipment Unsafe position Other First Additional InfoWas employee trained in the appropriate use of personal protective equipment/proper safety procedures? Yes No Was employee cautioned for failure to use personal protective equipment / proper safety procedures? Yes No Did employee promptly report the injury/illness? Yes No Is there modified duty available? Yes No Your Signature Select A Date MM slash DD slash YYYY
