CWU Accident Report Form admin    |    cwu home     


Employee or Student Employee:
Complete both sections below. (download & print copy)
Student or Visitor: Complete the first section below, only. (download & print copy)

TO BE COMPLETED BY INJURED PERSON:

Full Name: 
CWU ID:  
Email:        Visitor
Address: Phone:      
Date of Accident:   Time:   am pm          Where did the accident occur?
Type of injury:  Part of body injured:
Date Reported:  Time Reported:   am pm  Reported to:
Description of accident ( Include activities at the time of the accident, specific location, etc.):
Factors contributing to incident/accident:
Tools, chemicals, or equipment involved:
Suggestions for correcting conditions:
Witness Information (name, address, and phone number):
Treatment:
  Sent to physican   
  Admitted to hospital   
Medical treatment received:
I agree, to the best of my ability and knowledge, that all information I have given above is true and correct.

CWU EMPLOYEES (Complete this Section)

Accurately fill out each field below. Make sure your supervisor's name and email address are correct so that your supervisor receives email notification.

Employee Work Phone:  Work start time:   am pm  Department:
Position:
Could this accident have aggravated a previous work-related injury or illness? If yes, explain:
 
SUPERVISOR'S NAME:
 SUPERVISOR'S EMAIL:
 
CHECK OUTLOOK!! Make sure the supervisor email address is CORRECT, as an email notification will be sent.
 

   
   
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