Staff Accident/Incident Form

Staff Accident/Incident Report
Submitted by: Date of Report:  
  
1st person of authority notified:  
     
Affected person:    
     
Affected Person's Information
 
Last Name:First NameMI: 
Position:Program/Department: 
     
Street:   
City:   
State:   Zip: Phone Number: 
    
SSN:DOB: 
    
Status:# of dependent children:  
    
Will you return to work today? Will you return to work tomorrow?  
     
Date of Event:Time of Event: 
   
Was protective gear provided? Was protective gear worn?  
  
Location of event (be as specific as possible):  
  
List all people who witnessed the incident:  
 
Injury Information
 
Type of Injury (use Ctrl+ to select multiple types):    Other: 
   
1.  What side of the body?  1.  Body part/s injured?   
2.  What side of the body?  2.  Body part/s injured?   
3.  What side of the body?  3.  Body part/s injured?   
 
Nature of Injury:

How did the event occur? (Include cause, antecedants. DESCRIBE IN DETAIL

Nurses Report
Nurse's Name:Date: 

 

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