HTML Preview Employee Accident Report page number 1.
EMPLOYEE REPORT of ACCIDENT/INJURY
The employee must complete this report as soon as possible following an accident/injury. This report will be provided to the supervisor within 24 hours of the
accident/injury.
Name: Date of Injury: Time of Injury: AM PM
Social Security # Date of Birth: Work Phone # Home Phone #
Full Time Part Time Date Employed: Dept/Div:
Home Address:
Shift: A B C Start Time of Work Day: : AM PM
Witnesses (attach statement for each)
Name: Title: Phone Number:
Name: Title: Phone Number:
Name: Title: Phone Number:
Exact Location Injury Occurred: Duties Being Performed:
Describe the circumstances causing the injury:
Personal Protection Equipment Used:
Foot Protection. Face/Eye Protection. Fall Protection. Respiratory Protection. Hand Protection.
Head Prot. Apron/Chaps Back Belt None Lifting Assistance Device
Other: Object, equipment, or substance, which caused injury:
Choose factor (s), which directly or indirectly caused the accident to occur:
Struck by Flying/Thrown Object Caught in/Under/Between Objects Temperature Extremes
A Fall Struck by an Object/Person Rubbed or Abraded by Object
Bodily Reaction Electric Shock Struck Against Object
Blood/Fluid Exposure Other Disease Exposure Noise Exposure
Vehicle/Equipment Accident Toxic Material Exposure Repetitive Motion
Client Caused Client Assault Other-Describe
Nature of Injury:
Head Trunk Digestive Eye (s) R L B Wrist(s) R L B Ankle(S) R L B
Neck Abdomen Respiratory Shoulder(s) R L B Finger(s) T I M R P Foot/Feet R L B
Chest Groin Circulatory Arm (s) R L B Hip(s) R L B Toe(s) R L B
Back Skin Hand (s) R L B Other-Describe:
Medical Treatment:
No Treatment First Aid Employee Health Clinic Outside Medical Treatment
Employee’s Signature: Title: Date:
Supervisor’s Signature: Title: Date:
Distribution:
DHHS S&B Form 3010 E (06/30/09)
Print Form
Reset Form