Employee’s Report of Accident/Injury

Employee's Report of Accident/Injury

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Employee's name(Required)

Gender

Male

Famale

Date of birth

Telephone Number

Home Address

Present Position

Length of employment with MJH:

Location of accident:

Date of accident:

Time of accident

Describe fully how accident occurred: ( including events that occurred immediately before the accident):

Describe bodily in just sustained (be specific about body part (s) affected:

Recommendation on how to prevent this accident from recurring:

Name of supervisor:

Phone

Name(s) of witness(es):

Phone

When did you report accident to your supervisor?

Who did you report the injury to?

Do you require medical attention?

Yes

Maybe

Signature of employee

Date