Employee Accident Report

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					EMPLOYEE ACCIDENT REPORT




This Employee Accident Report is used to record the details of an accident in which an
employee is involved at work. The accident information includes the names of the
physician and hospital, witnesses, along with comments and the employee's current
work status. It is important to keep detailed records of employee accidents in case
potential claims arise from the accident and also so the employer can improve
employee safety in the workplace. This form should be used by an employee involved
in an accident at work.




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                                      EMPLOYEE ACCIDENT REPORT


 Employee Information                                        Accident Information
 Name                                                        Date
 Age                                                         Time
 SS #                                                        Location
 Position                                                    Witness


 Describe, in detail, what happened including times and location.




 Describe all injuries in detail including any part of the body effected.




 NAME AND ADDRESS OF PHYSICIAN                                   IF APPLICABLE, NAME & ADDRESS OF HOSPITAL




 COMMENTS FROM WITNESSES                                         OTHER COMMENTS




 WORK STATUS
 Did the employee return to work?                                                               YES       NO
 If no, when was the day and time at work?


 (Signature of Employee)                             (Date)               (Signature of Supervisor)
 (Date)



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                                          EMPLOYEE ACCIDENT REPORT


				
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Description: This Employee Accident Report is used to record the details of an accident in which an employee is involved at work. The accident information includes the names of the physician and hospital, witnesses, along with comments and the employee's current work status. It is important to keep detailed records of employee accidents in case potential claims arise from the accident and also so the employer can improve employee safety in the workplace. This form should be used by an employee involved in an accident at work.