Work-Related Accident Report Form Template
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Work-Related Accident Report Form
Please fill out this form completely to report a work-related accident or injury.
Employee Information
Name
Job Title
Department
Phone number
Accident Details
Date and Time of Accident
Location of Accident
Describe the Accident
Was there an injury?
If yes, describe the injury
Witness Information
Were there any witnesses?
If yes, please provide details:
Name
Phone number
Actions Taken
Was medical attention required?
If yes, describe the treatment provided
What immediate actions were taken following the accident?
Signature
By signing this form, I confirm that the information provided is accurate to the best of my knowledge.
Name:
Date:
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