WORK RELATED ACCIDENT REPORT INSTRUCTIONS 1. Completely fill out this form for all job related injuries and property damage accidents. 2. Call the home office to report the accident 3. If possible, the supervisor and the injured employee should sign the form. 4. Forward two copies of the form to the home office within 24 hours. 5. If the company is liable, then instruct everyone to send all bills to the home office. INFORMATION ABOUT THE INJURED Name: ________________________________________
Length of Employment: __________
Home Address: _________________________________
Age: ______ Date of Birth: ______
City: _________________________________________
State: ___________ Zip: ________
Home Phone No.: _______________________________
Sex:
Soc. Sec. No.: __________________________________
Marital Status: Married
Male Female Single
Job Title: ______________________________________ No. of Dependents: _____________ Fatality?
Yes
No
Will employee be off from work?
Yes
No
How Long? ________ Days
INFORMATION ABOUT THE ACCIDENT Date And Time Of Accident: _______________________ Date Reported: ________________ Job Name: ______________________________________ Job No.: ______________________ Address: _______________________________________ City: _____________ State: ______ Supervisor: ______________________________________
Describe Nature of Injury and/or Property Damage: ____________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Describe What Happened and Probable Cause Of Accident: _____________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Section IV: Posting & Reporting Accidents – Work Related Accident Report
Rev. 08/10
Name of Physician or Hospital Where Treatment Was Sought: ___________________________ ______________________________________________________________________________
Names of Witnesses
Home Phone Numbers of Witnesses
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________ Injured Employee's Signature
__________________________________ Supervisor's Signature
Section IV: Posting & Reporting Accidents – Work Related Accident Report
Rev. 08/10
