Employee’s Accident Report
Step
1
of
2
50%
Employee Name
*
First
Last
Email
Enter Email
Confirm Email
Hire Date
*
MM slash DD slash YYYY
Last 4 SS#
*
Home Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone Number
*
Birth Date
*
MM slash DD slash YYYY
Pay Rate
*
Facility Name
*
Facility Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Facility Phone Number
*
Project Name
*
Contractor or Employer
*
Accident Date
*
MM slash DD slash YYYY
Accident Time
*
:
Hours
Minutes
AM
PM
AM/PM
Date Reported
MM slash DD slash YYYY
Accident location
*
Injured employee
*
What was employee doing when accident occurred?
*
What object or substance affected the employee?
*
Describe injury in detail (body part, etc.)
*
Failure to obey safety rule?
*
Yes
No
Failure to use safety device?
*
Yes
No
Intoxication/Alcohol/Drugs?
*
Yes
No
Name of witness
*
Employee refuses medical treatment
Signature of Employee
*
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