Accident Report Form | Central Washington University

Employee Status

Employee

Student Employee

Student

Visitor

First Name

Last Name

Email

Phone

Date of Accident

Please enter a valid date.

(MM/DD/YYYY)

Time of Accident

Please enter a valid timestamp

Ex: 4:00PM or 04:00 PM

Where did the accident occur?

Type of injury

Body part injured

Time Reported

Please enter a valid timestamp

Ex: 4:00PM or 04:00 PM

Reported to

Description of Accident

Factors contributing to accident

Chemicals or equipment involved

Field is required

Suggestions for corrective actions

Witness information

Treatment

Sent to physician?

Yes

No

Physician's Name

Admitted to Hospital?

Yes

No

Hospital Name

Medical Treatment Received

Work start time

Please enter a valid timestamp

Ex: 4:00PM or 04:00 PM

Department

Facilities Work Order Submitted?

Yes

No

Field is required

Position

Work Status

Supervisor's Name

Supervisor's Email

Field needs to be a valid email address.

Employee Work Phone

Please enter a valid phone number.

I agree, to the best of my ability and knowledge, that all information I have given above is true and correct:

Field is required