Employee Accident Report

General Information

Information about the person reporting the accident.

Your full name:

Your position/title:

Your phone number:

Your email address:

Email address must be of a valid format.

Urgency of this report(Required):

This field is required.

Date of incident(Required):

This field is required.

Time of incident:

Location of incident(Required):

This field is required.

Specific location:

Employee Information

Information about the employee involved in this accident/incident.

Full Name

Gender

Select Role

ID number

DOB (YYYY-MM-DD)

Personal phone number

Email address

Last 4 digits of SSN

Accident Information

Information about the accident.

The Human Resources Department will need to complete an Authorization to Treat form for injuries that require medical treatment. The HR Department will provide the form to you immediately after submission of this report.

Who witnessed the accident/incident? Please list name and address. To enter multiple names, separate with comma. This field is required.

Describe fully how the accident happened.(Required) This field is required.

If injury resulted, what parts of the body were injured? This field is required.

Did you stop working as a result of the accident?(Required)

Yes No

This field is required.

If work stopped, when did it stop? This field is required.

Was your pay continued during any part of your disability?(Required)

Yes No

This field is required.

If yes, for what period or when was your last pay day? This field is required.

What date do you expect to return to work? This field is required.

From whom did you receive first medical treatment? This field is required.

How often do you receive treatment? This field is required.

What is the name, address and phone number of the doctor treating you? This field is required.

Please list the number of hours and days worked per week. This field is required.

Martial Status:(Required)

Married Unmarried (Single, Widowed, Divorced) Separated

This field is required.

If you have dependent children under 21 years of age living with you, please list their name and date of birth This field is required.

Which of the above children were not at least 50% supported by you? This field is required.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

General Information

Employee Information

Accident Information

Supporting Documentation

Submission