Swain County
Accident Investigation Report
Date: _________________________ Completed by: __________________________________
I. GENERAL INFORMATION
Employee Name:_____________________________________________________________
Home Address: ______________________________________________________________
Home Phone Number __________________Cell Phone Number ______________________
Date of Accident:_________________________ Time: _____:_____ A.M./P.M.
Job Title: _______________________________ Supervisor: _________________________
Location of Accident (be specific):
___________________________________________________________________________
___________________________________________________________________________
Date and Location of First Treatment: ____________________________________________
II. DESCRIPTION OF INJURY OR ILLNESS
Injury: _________________________________ Body Part Affected: __________________
Medical Treatment Required: Yes_______ No _______
Hospital______ Urgent Care ________ Doctor’s Office ______ Other _____________
Name of Facility: _______________________________________________________
Address and Telephone Number (if known):
___________________________________________________________________________
___________________________________________________________________________
Name of Attending Physician: __________________________________________________
III. DESCRIPTION OF ACCIDENT
Please describe the accident, how did it occur? Why? (use back of sheet if more space
needed):______________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
