First Report of Accident or Injury Form

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First Report of Accident or Injury Form Powered By Docstoc
					This is a template that can be used by a company as a first report of an accident or
injury to an employee at the workplace. This template includes the name of the
employee, date of the injury, location of the accident, how and why the injury occurred,
and the nature of the injury. Additionally, it can be customized to provide for any
additional industry-specific language that may be necessary. This document should be
used by small businesses or other entities to record an employee injury at the outset of
its occurrence.
                       FIRST REPORT OF ACCIDENT OR INJURY FORM
                                                                          Today’s Date:
                                                                          Time of Report:
Information on Injured Employee
Name
Social Security Number
Date of Birth
Current Home Address
Day Phone Number
Evening Phone Number

Information on Accident/Injury
Date of Injury
Time of Injury
Location of Accident
Nature of Injury
Part of Body Injured
Last day of work after injury
Date of return to work
Describe treatment sought
Attending Physician’s
Name/Address
Hospitalization required?
Prognosis



Cause of Accident
Description of how accident
happened
Specify machinery, tools, or
substances connected with
accident
What was employee doing when
accident occurred
If anyone else was involved,
witnessed or caused accident,
give name and address
Employment/Assignment Information
Assignment location:
On-Site Supervisor Name and Phone Number:
Work schedule & time work began this day:

 _______________                                       ______________________________________________
 Date/Time                                               Signature of Representative Obtaining Information
 Recv’d in HR:                                         Complete and submit to HR within 2 hours of notification
                                                        Do not leave any fields blank - Notate N/A if field is Not Applicable
 _______________
 HR Signature


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DOCUMENT INFO
Description: This is a template that can be used by a company as a first report of an accident or injury to an employee at the workplace. This template includes the name of the employee, date of the injury, location of the accident, how and why the injury occurred, and the nature of the injury. Additionally, it can be customized to provide for any additional industry-specific language that may be necessary. This document should be used by small businesses or other entities to record an employee injury at the outset of its occurrence.