Employee Accident/Injury Report Form

for Your State

Employee Accident/Injury Report which will effectively document the details of an employee's accident or injury while on the job. This form can easily be customized to fit your unique needs.

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This Employee Accident/Injury Report will clearly and efficiently document an injury or accident suffered by an employee while on the job. This report sets out details regarding the employee, date and time of the incident and type of accident or injury. It also sets out if medical attention was required. It is imperative that an on the job injury or accident be clearly documented. A written Employee Accident/Injury Report will prove invaluable in the event there are disagreements, misunderstandings or litigation resulting from the incident.

This Employee Accident/Injury Report includes the following information:
  • Employee: Employee's name, social security number, job title, date of hire and department in which he or she works;
  • Accident/Injury Information: Details regarding the date, time and location of the accident or injury, if medical assistance was necessary and remarks about the incident.

Protect your rights by using our forms which are up-to-date and prepared by attorneys.

This attorney-prepared packet contains:
  1. General Instructions
  2. Employee Accident/Injury Report
State Law Compliance: This form complies with the laws of all states
Number of Pages2
DimensionsDesigned for Letter Size (8.5" x 11")
EditableYes (.doc, .wpd and .rtf)
UsageUnlimited number of prints
Product number#29255
This is the content of the form and is provided for your convenience. It is not necessarily what the actual form looks like and does not include the information, instructions and other materials that come with the form you would purchase. An actual sample can also be viewed by clicking on the "Sample Form" near the top left of this page.















Employee Accident/Injury Report Form









This Packet Includes:
1. Information
2. Employee Accident/Injury Report Form 





Information
Employee Accident/Injury Report Form

This form provides a method to report a workplace accident and/or injury. The careful use of this form can provide an employer with important records in the event of the workers compensation claims and/or other insurance-related matters.







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Employee Accident/Injury Report

Date of Incident:

Time of Incident:
Employee Name


Social Security Number


Job Title


Department


Date hired






Type of Accident or Injury

Medical Assistance Provided by Employer

Remarks


























Signature of Employer ____________________________________
Date _______________________


Signature of Employee ____________________________________
Date _______________________

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