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Employee Accident Report
This report allows you to easily document a workplace injury or accident. Complete the details of the incident within the report then have each witness write a statement. Both the employee and supervisor should sign the report when completed.

Free Sample Template
Format: Word PDF
# of Pages: 1
Printable: Yes


Other forms related to workplace accidents
About Employee Accidents
Sample Employee Letter
Accident Analysis Worksheet
Accident Report Log


Employee Accident Report TemplateForm 1006
Format: Word PDF
Category: Employee, Accident
Type: Report
Employee Accident or Injury Report


Name:_______________________________ Date and Time of Injury: _____________________________ AM / PM

Social Security Number: _____________________ Date of Birth: __/__/____

Work Phone Number: _______________________ Home Phone Number: _________________________________

Full Time: ___ Part Time: ___ Start Date of Employment: __/__/____ Department / Division: _____________

Home Address: _________________________________________________________________________________

For each witness please attach a statement.

Witnesses:

Name: ________________________________ Title: ______________ Phone Number: _______________________

Name: ________________________________ Title: ______________ Phone Number: _______________________

Name: ________________________________ Title: ______________ Phone Number: _______________________

Location Injury Occurred: ________________________________________________________________________

Duties Being Performed: _________________________________________________________________________

Specific circumstances that caused the injury:

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Medical Treatment:

___ No Treatment Needed ___First Aid ___ Employee Health Clinic ___ Outside Medical Treatment

Employee’s Signature: ________________________________________ Title: _____________ Date: __/__/____

Supervisor’s Signature: _______________________________________ Title: ______________ Date: __/__/____