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Accident Form-Personal Injury

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									         Daily Equipment Company

REPORTING ACCIDENTS—PERSONAL INJURY

1. Who was involved? Employee Name _________________________________________________

   Address ____________________________________________ City ______________________

   Phone _____________________ SSN _________________________________________

Date of Accident ___________________________ Time of Accident____________________

Location__________________________________

2. Describe what happened. ___________________________________________________________

   ________________________________________________________________________________

   ________________________________________________________________________________

   ________________________________________________________________________________


3. Describe the injury. _______________________________________________________________

  ________________________________________________________________________________

  ________________________________________________________________________________


4. What was the cause of the accident? _________________________________________________

  _______________________________________________________________________________

  _______________________________________________________________________________

5. What could you have been done to avoid this accident? _________________________________

  _______________________________________________________________________________

  _______________________________________________________________________________

6. Where did you go for treatment?   ___________________________________________________


_______________________________Date________         ___________________________________
Employee Signature                                  Supervisor Signature

7. Resolution: Returned to work (date)_________ Full release (date) ________________________
Return visit to doctor (date) __________________ Other notes______________________________
_________________________________________________________________________________


         Corporate Office: 1859 Old Whitfield Road, P.O. Box 98209, Jackson, MS 39289-8209
                              Phone (601) 932-6011 Fax (601) 932-2311

								
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