Fill and Sign the Accident and Incideent Form

Accident/Injury Report Complete immediately and forward to Human Resources within 24 Hours of Accident Name of Injured Employee       ID#       Dept.       Job Title        Regular Temporary Agency Injury Date       Time       AM PM Date Reported       Last day employee worked       (If no time was lost, write “same”) Date returned to work       Supervisor       Reported by       Witnesses       Where did injury occur (state location and building if multiple sites)?                   WHAT HAPPENED : What was employee doing when accident occurred?                   How did accident occur?                   Did equipment malfunction? No Yes Explain:                   What unsafe acts or conditions contributed to this accident?             MEDICAL: Describe the injury (for example, cut, strain, fracture, etc.):                   Accident/Injury Report Page 1 of 2 Have medical services been given to the employee? No Yes If yes, list name and address of all doctors, hospitals, medics or other medical personnel consulted:             If medical services were sought at a later date, explain:             Please attach an additional sheet if more room is necessary. Accident/Injury Report Page 2 of 2