Workplace Accident Report Form by darrenv

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									                   ACCIDENT REPORT FORM


UNDER WAC 296-24-040, CHAPTER 295.24, ALL ACCIDENTS AND INJURIES
OCCURING IN THE WORKPLACE SHALL BE REPORTED FOR OSHA
RECORDKEEPIN'G PURPOSES WITHIN THESE GUIDELINES: (A) Unconsciousness,
(B) Inability to perform all phases of regular job, (C) Inability to work full-time on regular
job, (D) Temporary assignment to another job, (E) Medical treatment beyond first aid.


THIS FORM SHOULD BE FILLED OUT PROMPTLY AND RETURNED TO THE
HUMAN RESOURCE OFFICE (RM. #268). PLEASE PRINT CLEARLY.



Employee Name                                                       SSN:

Home Address:

City/State/Zip:                                          Phone #:

Department:                                     Position Title:

Supervisor:


(For H/R Office Use Only)

Date Accident Form Reviewed:

Accident Investigation Conducted? Yes          No

Reason:

Conclusion or Comments:




Received by H/R Office:
                              (Signature)                (Title)                     (Date)



                  PLEASE COMPLETE OTHER SIDE OF THIS FORM




Copy: Safety Committee                                                       Revised 8/08/2005
                                ACCIDENT/INJURY INFORMATION


                     Please fill out completely and use extra sheet of paper if necessary.



 Time and Date of the accident/injury:

 Location of the accident/injury:

 To whom was the accident/injury reported:

 Witnesses:
(If non-employee, include contact phone number)



 Time shift started:                                   Date expected to return to work:

 What were you doing when the accident/injury occurred?




 Describe how the accident/injury occurred:




 Describe the specific injuries resulting from the accident/injury in detail:




 NAME/ADDRESS OF PHYSICIAN/HOSPITAL TREATING INJURIES:




I CERTIFY THAT THE INFORMATION FURNISHED ON THIS FORM IS TRUE AND CORRECT TO
THE BEST OF MY KNOWLEDGE.




                                        (SIGNATURE OF PERSON INJURED/INVOLVED)                   (DATE)



                                        (SGNATURE OF PERSON COMPLETEING FORM)                    (DATE)



Copy: Safety Committee                                                                   Revised 8/08/2005

								
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