Accident Report Form for Employees Template
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Accident Report Form for Employees
Please fill out this form completely to report details of the workplace accident.
Employee Information
Name
Job Title
Department
Phone number
Accident Details
Date and Time of Accident
Location of Accident
Describe the accident in detail (what happened, how it occurred)
Were there any witnesses?
If yes, provide the following details:
Name
Phone number
Injuries Sustained
Describe any injuries sustained (if applicable)
Was medical attention sought?
If yes, provide details of the treatment
Signature
By signing below, I confirm that the information provided in this report is accurate to the best of my knowledge.
Name:
Date:
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