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
Employee Name: _______________________________
Date of Birth: ___________________________________
Date Incident occurred: ______________________________
Time incident occurred: ______________________________
Nature of Injury: ____________________________________
Details how injury occurred: ___________________________
Treatment provided: __________________________________
Name & Address: _______________________________________
I hereby certify that all information provided hereunder is correct.