Please use the form below to include any additional members of staff who may have been injured in the initial report.
Injured Employees Name
Injured Employees Title
Date of Incident
Time of Incident (use 24 hour format)
Location of Incident
What body part(s) were affected and how?
Were others involved? If so, list their names and injuries:
Were there any witnesses? If so, list their names:
Anyone taken from scene in ambulance? If yes, who:
List Physician / Clinic / Hospital:
Drug & Alcohol Post Incident / Accident Test Performed:
Drug & Alcohol Test Completed By:
Date of Test