An accident report form documents an incident that occurred on a specific date and time. It records information about the injured person such as their name, address, date of birth, and type of injury. Details of the incident are described. The form also notes whether medical attention was required and includes signature lines for the injured party.
An accident report form documents an incident that occurred on a specific date and time. It records information about the injured person such as their name, address, date of birth, and type of injury. Details of the incident are described. The form also notes whether medical attention was required and includes signature lines for the injured party.
An accident report form documents an incident that occurred on a specific date and time. It records information about the injured person such as their name, address, date of birth, and type of injury. Details of the incident are described. The form also notes whether medical attention was required and includes signature lines for the injured party.
Date of incident: _______________ Time: ________ AM/PM
Name of injured person: Address: Phone Number(s): Date of birth: ________________ Male ______ Female _______ ho !as injured person"(circle one) Passen#er $%stem &mplo%ee T%pe of injur%: Details of incident:
'njur% re(uires ph%sician/hospital )isit" *es ___ No _____ Name of ph%sician/hospital: Address: Ph%sician/hospital phone number: $i#nature of injured part% _________________________________________________________ Date +No medical attention !as desired and/or re(uired,
$i#nature of injured part% Date -eturn this form to $afet% .oordinator !ithin /0 hours of incident, 12/30/30 /45303454,doc 3/3