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ACCIDENT

ACCIDENT // INCIDENT
INCIDENT REPORT
REPORT
(To
be
completed
by
EmployeePlease
print legibly)
legibly)
(To be completed by Employee- Please print
Name_________________________________________________________
SS#
________________________________
Name_________________________________________________________ SS# ________________________________
Home
__________________________
Home Address__________________________________________________
Address__________________________________________________ Birth
Birth Date
Date __________________________
City/State/Zip
__________________________________________________
Sex:

� Female
Female
City/State/Zip __________________________________________________ Sex:
� Male
Male

Telephone:
(
)
______________________________________
Alternate
Phone:
(
)
_____________________
Telephone: (
) ______________________________________ Alternate Phone: (
) _____________________
   
Date
Date of
of injury
injury or
or onset
onset of
of symptoms
symptoms _________________________________________
_________________________________________ Time____________
Time____________ �
� am
am �
� pm
pm
Describe
what
causes
the
injury/symptoms,
what
were
you
doing
just
before
the
incident,
and
what
did
you
do
after
the
Describe what causes the injury/symptoms, what were you doing just before the incident, and what did you do after the
incident
any objects
objects or
or substances
substances involved:
involved:
incident (if
(if you
you need
need more
more space,
space, write
write on
on back
back of
of this
this form)
form) Be
Be specific-name
specific-name any
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Did
□ Yes
Yes □
□ No
No If
If yes,
yes, who?
who? ________________________________________________
________________________________________________
Did anyone
anyone see
see you
you get
get hurt?
hurt? □
Did
If not,
not, why
why not?
not? _______________________________________
_______________________________________
Did you
you report
report this
this incident
incident to
to anyone?
anyone? □
□ Yes
Yes □
□ No
No If
If
If yes,
yes, to
to whom
whom did
did you
you report
report it?
it? (Name
(Name and
and Title/Position)_________________________________________________
Title/Position)_________________________________________________
When?
(Date
and
Time)______________________________________________________________________________
When? (Date and Time)______________________________________________________________________________
What
for example:
example: right
right elbow,
elbow, left
left knee,
knee, right
right index
index finger):
finger):
What part(s)
part(s) of
of your
your body
body was/were
was/were affected?
affected? (Be
(Be specific
specific –– for
_________________________________________________________________________________________________
_________________________________________________________________________________________________
What
for example:
example: bruise,
bruise, scrape,
scrape, laceration,
laceration, pull)
pull)
What type
type of
of injury
injury did
did you
you experience?
experience? (Be
(Be specific
specific –– for
________________________________________________________________________________________________
________________________________________________________________________________________________
Was
if yes,
yes, describe:_______________________________________
describe:_______________________________________
Was any
any first
first aid
aid provided
provided at
at the
the scene?
scene? □
□ Yes
Yes □
□ No
No if
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Did
seek other
other medical
medical treatment?
treatment? □
If yes,
yes, when?
when? _________________________________________
_________________________________________
Did you
you seek
□ Yes
Yes □
□ No
No If
Where?_____________________________________
If
treatment
was
Where?_____________________________________ If treatment was not
not sought
sought immediately,
immediately, explain
explain why:
why:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Is

Is this
this an
an aggravation
aggravation of
of aa previous
previous injury/symptom?
injury/symptom?
□ Yes
Yes □
□ No
No If
If yes,
yes, when
when were
were you
you last
last treated
treated for
for the
the
previous
injury?____________________________________
By
whom
or
where?
_______________________________
previous injury?____________________________________ By whom or where? _______________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Have
□ Yes
Yes □
□ No
No If
If yes,
yes, describe
describe other
other injury:
injury: _____________________________
_____________________________
Have you
you ever
ever had
had aa similar
similar injury?
injury?

__________________________________________________________________________________________________
__________________________________________________________________________________________________

Medical
Medical Release
Release
II hereby
authorize
any
person(s)
who
have
in
the
past
or
will
hereby authorize any person(s) who have in the past or will in
in the
the future
future medically
medically attend,
attend, treat
treat or
or examine
examine me,
me, or
or any
any person
person who
who
may
have
information
of
any
kind
which
may
be
used
to
reach
a
decision
in
any
claim
for
injury
or
disease
arising
from
the
may have information of any kind which may be used to reach a decision in any claim for injury or disease arising from the
injury/illness
injury/illness described
described above,
above, to
to disclose
disclose such
such information
information to
to my
my employer
employer and
and to
to any
any of
of my
my employer’s
employer’s designated
designated representative(s).
representative(s).
A
copy
of
this
form
will
serve
as
the
original.
A copy of this form will serve as the original.
Employee
Name (Print)
(Print) _______________________________________
_______________________________________ Signature
Employee Name
Signature _______________________________________
_______________________________________
Date
Date (Required)_____________________________________________
(Required)_____________________________________________