Name of Injured Party

Location of Accident

Date and Time of Accident

Number of Injured Party

Job Title

Phone number

Describe the Accident

Witness Name 1

Phone number

Witness Name 2

Phone number

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Were there any injuries?

• Yes

• No

If yes, please input the details of the injury sustained.

Body Part(s) Affected

Medical Attention Needed?

• Yes

• No

Immediate Actions Taken

Name of Reporting Person