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Employee Accident Report

Location of Accident:

Name of Injured:

Phone:

Employee's Address:

Date of Birth

Gender:

Marital Status:

Number of Dependents:

Job Title:

Employer:

Employee Classification:

Date of Hire:

Supervisor Name:

Date of Injury:

Time of Injury:

Average Hours Worked Each Day:

Average Hours Worked Each Week:

Paid For The Day of the Injury:

Description of Accident:

Description of Injury:

Where Accident Occurred:

How Accident Occurred:

Contributing Factors:

Witnesses:

How Could Accident Be Avoided:

Acknowledgement of Statement:

Person Reporting Incident:

Date Person Reported Incident:

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