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Employee Accident Report

Printable form to report an employee accident or injury that occurs while at work








Employee Accident Report


The printable report provides blank space for details on the employee and accident. Accident fields include physician and hospital, witness, comments plus work status.

EMPLOYEE INFORMATION ACCIDENT INFORMATION
NAME DATE
AGE TIME
SS # LOCATION
POSITION WITNESS
DESCRIBE WHAT HAPPENED IN DETAIL INCLUDING TIMES AND LOCATIONS




DESCRIBE ALL INJURIES IN DETAIL INCLUDING ANY PART OF THE BODY EFFECTED




NAME AND ADDRESS OF PHYSICIAN NAME & ADDRESS OF HOSPITAL
COMMENTS FROM WITNESSES OTHER COMMENTS
WORK STATUS
EMPLOYEE
SUPERVISOR






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