ACCIDENT / INJURY REPORT - EMPLOYEE
Location of plant where accident occurred. No. & Street / City
Did accident occur on employer's premises? Yes No County / State / Zip
Department Department regularly employed in
Date Day of week Hour of day am pm
First day unable to work am pm Was injured paid in full for this day?
When did you or supervisor first know of injury? Name of supervisor
Name of injured (full first, middle initial, last name)
Social Security No. Workers' Comp Code
Address No. & Street / City / State / Zip
Telephone Telephone Friend or Relative Speak English?
Age Sex Marital Status Minor Child
Occupation when injured Was this his / her regular occupation?
Piece or time worker? Wages per hour $ Date of hire
Machine, tool or thing causing injury
Part of machine on which accident occurred
Name the safety appliance or regulation provided Was it in use at time?
Describe fully how accident occurred, and state what employee was doing when injured
Names and addresses of witnesses
Describe the injury in detail and indicate the part of body affected
CORRECTIVE ACTION: _______________________________________________
The above is true and correct to the best of my knowledge. If any corrective action is needed, I agree to comply
with such action and all other safety rules. I understand that falsification of an injury or exaggeration of symptoms
to obtain medical benefits or for financial gain is strictly against the law and that I may be prosecuted
for such actions. Focus investigates all injuries and will pursue legal action if fraud is suspected or discovered.
Injured Employee Signature: _________________________________________________
Report Completed by: _______________________________________________________