Office of Human Resources
Accident or Injury Report
Employee’s Report of Accident or Injury
Employee Name:
Location: Attending physician:
Occupation: Age:
Date of injury: Time:
A.M. P.M.
Nature of injury (such as strain, cut, or bruise):
Part of body that was injured (such as left hand or right ankle):
Did you return to work? Yes No
A.M. P.M.
Where and how did the accident happen?
Specify any equipment, substance, or object connected with the accident or injury:
What were you doing at the time of the accident or injury?
Employee signature: Date:
Supervisor signature: Date:
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