Free Employee Accident/Injury Report Form

This Employee Accident/Injury Form is submitted to an employer by an employee who has suffered an accident or injury while on the job. This form contains the name of employee, the date and time of the incident, nature and details of the accident or injury and any treatment provided. This Employee Accident/Injury Form must be signed by the employee who certifies that the information is true and correct.

Disclaimer:This was not drafted by an attorney & should not be used as a legal document.




EMPLOYEE ACCIDENT/INJURY FORM

PERSONAL INFORMATION
Employee Name: _______________________________
Title: _________________________________________
Address: ______________________________________
______________________________________________
Phone: ________________________________________
Date of Birth: ___________________________________
Gender: ________________________________________
INCIDENT DETAILS
Date Incident occurred: ______________________________
Time incident occurred: ______________________________
Address: __________________________________________
__________________________________________________
Nature of Injury: ____________________________________
__________________________________________________
Details how injury occurred: ___________________________
___________________________________________________
___________________________________________________
TREATMENT
Treatment provided: __________________________________
_____________________________________________________
Name & Address: _______________________________________
______________________________________________________


I hereby certify that all information provided hereunder is correct.
____________________________________________
Signature

___________________________
Date



The forms on this site are provided "As-Is." By using these forms you agree that you are using them at your own risk. Most of the free forms are not prepared by an attorney and may need substantial modification. Additional disclaimers can be found in our Terms of Use.