Please complete the below Accident & Injury Form below. Employees should report an occupational injury to their supervisor immediately and seek medical care when necessary. Name Your email Date Time Explain in detail Describe clearly how the incident occurred: What was the employee doing when the incident occurred? Physical Cause of Incident Defective tools or equipmentPoor housekeepingUnguarded equipmentCongested areaUnstable StorageImproper apparelImproper lightImproper ventilationImproper TemperatureOther (check all that apply) If Other, please explain Personal Cause of Incident Not properly trainedFailure to use PPEFailure to follow rulesUsing improper toolsHorseplayUsing improper methodsOperating without auth.Other Check all that apply If Other, please explain: Nature of Injury and Body Parts Injured: Machinery Involved?* YesNo Chemicals Involved?* YesNo Was first aid administered at the job site? Hospital Information Hospital Transported To: How were you transported? Insert the time you were transported. At what time? Injured: Print your name Injured: Please draw/sign your signature below the line. Witness Information Witness Statement: For the witness Print your name By signing below, I understand that I may be called to testify in a court of law as to what I have witnessed. Witness: Please draw/sign your signature below the line. AUTHORIZED PERSONEL ONLY Reviewed by: Supervisors Name: Supervisors Signature: Follow-Up Follow-Up Action: NOTE: Follow-up within 30 days of accident to check progress, and each 30 days thereafter as needed to fully implement preventative or remedial measures. How many days did the employee miss or take off from work as a result of the injury? How many days was the employee on modified job duty as a result of the injury? Follow-Up Approved by: Supervisors Name: Supervisors Signature: Δ [signature signature-666 background:#cccccc color:#000000]