Employee Accident Report
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The printable report provides blank space for details on the employee and accident. Accident fields
include physician and hospital, witness, comments plus work status.
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EMPLOYEE INFORMATION
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ACCIDENT INFORMATION
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NAME
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DATE
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AGE
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TIME
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SS #
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LOCATION
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POSITION
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WITNESS
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DESCRIBE WHAT HAPPENED IN DETAIL INCLUDING TIMES AND LOCATIONS
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DESCRIBE ALL INJURIES IN DETAIL INCLUDING ANY PART OF THE BODY EFFECTED
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NAME AND ADDRESS OF PHYSICIAN
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NAME & ADDRESS OF HOSPITAL
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COMMENTS FROM WITNESSES
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OTHER COMMENTS
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WORK STATUS
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EMPLOYEE
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SUPERVISOR
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