Basic Information

Company Name:

Managers Name:

Managers Title:

Managers Email Address:

Managers Contact Number:

Injured Employees Name:

Injured Employees Title:

Injured Employees Address:

Injured Employees Number:

Gender:

Date of Incident Known?
NoYes

Date of Incident:

Time of Incident (use 24 hour format)

Date Incident was Reported to Manager:

Time Incident was Reported to Manager:(use 24 hour format)

Location of Incident

Indoors or Outdoors?
IndoorsOutdoors

Brief Description of Incident

Injury Specifics

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:

Medical Treatment

Anyone taken from scene in ambulance? If yes, who:

List Physician / Clinic / Hospital:

Drug & Alcohol Post Incident / Accident Test Performed:
YesNo

Drug & Alcohol Test Completed By:

Date of Test

Vehicle Incident Specifics (If Applicable)

Weather/Road Conditions:

Vehicle One

Vehicle 1:
PersonalCompany

Tag #

Was the Vehicle Towed:
YesNo

If yes, where:

Driver’s Name:

Year

Make

Model

Color

Description of Damage:

Vehicle Two

Vehicle 2:
PersonalCompany

Tag #

Was the Vehicle Towed:
YesNo

If yes, where:

Driver’s Name:

Year

Make

Model

Color

Description of Damage:

Additional Vehicle’s Insurance Company:

Policy #:

Police Report

Were police called to the scene?
NoYes

Any citations issued?:
NoYes

Police Report #:

Police Dept. Location:

Who responded?
N/ASherriffState TrooperLocal Police

Incident Photos or Forms

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