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Accident & Injury Report

    Please complete the below Accident & Injury Form below. Employees should report an occupational injury to their supervisor immediately and seek medical care when necessary.










    Explain in detail




    Defective tools or equipmentPoor housekeepingUnguarded equipmentCongested areaUnstable StorageImproper apparelImproper lightImproper ventilationImproper TemperatureOther

    (check all that apply)




    Not properly trainedFailure to use PPEFailure to follow rulesUsing improper toolsHorseplayUsing improper methodsOperating without auth.Other

    Check all that apply






    YesNo

    YesNo


    Hospital Information







    Insert the time you were transported.


    Injured: Please draw/sign your signature below the line.



    Witness Information





    For the witness

    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



    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:



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