First Name

Last Name

Email

Phone

Date of Accident

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(MM/DD/YYYY)

Time of Accident

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Ex: 4:00PM or 04:00 PM

Where did the accident occur?

Type of injury

Body part injured

Time Reported

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Ex: 4:00PM or 04:00 PM

Reported to

Description of Accident

Factors contributing to accident

Chemicals or equipment involved

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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

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Ex: 4:00PM or 04:00 PM

Department

Facilities Work Order Submitted?

Yes

No

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Position

Work Status

Supervisor's Name

Supervisor's Email

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Employee Work Phone

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

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