Fillable Printable Employee Report of Accident/Injury

Employee Report of Accident/Injury

EMPLOYEE REPORT of ACCIDENT/INJURY

The employee must complete this report as soon as possible following an accident/injury. This report will be provided to the supervisor within 24 hours of the

accident/injury.

Name: Date of Injury: Time of Injury: AM PM

Social Security # Date of Birth: Work Phone # Home Phone #

Full Time Part Time Date Employed: Dept/Div:

Home Address:

Shift: A B C Start Time of Work Day: : AM PM

Witnesses (attach statement for each)

Name: Title: Phone Number:

Exact Location Injury Occurred: Duties Being Performed:

Describe the circumstances causing the injury:

Personal Protection Equipment Used:

Foot Protection. Face/E ye Protection. Fall Protection. Respiratory Protection. Hand Protection.

Head Prot. Apron/Chaps Back Belt None Lifting Assistance De vice

Other: Object, equipment, or substance, which caused injury:

Choose factor (s), which directly or indirectly caused the accident to occur:

Struck by Flying/Thrown Object Caught in/Under / Between Objects Temperature Extremes

A Fall Struck by an Object/Person Rub be d or Abraded by Objec t

Bodily Reaction Electric Shock Struck Against Object

Blood/Fluid Exposure Other Disease Exposure Noise Exposure

Vehicle/Equipme nt Ac c i dent Toxic Material Exposu re Repetitive Motion

Client Caused Client Assault Other-Describe

Nature of Injury:

Head Trunk Digestive Eye (s) R L B Wrist(s) R L B Ankle(S) R L B

Neck Abdomen Respiratory Shoulder(s) R L B Finger(s) T I M R P Foot/Feet R L B

Chest Groin Circulatory Arm (s) R L B Hip(s) R L B Toe(s) R L B

Back Skin Hand (s) R L B Other-Describe:

Medical Treatment:

No Treatment First Aid Employee Health Clinic Outside Medical Treatment

Employee’s Signature: Title: Date:

Supervisor’s Signature: Title: Date:

Distribution:

DHHS S&B Form 3010 E (06/30/09)