Employee Accident Report Form
Employee Accident Report
Location of Accident:
Name of Injured:
Phone:
Employee's Address:
Date of Birth
Gender:
Male
Female
Marital Status:
Single
Married
Other
Number of Dependents:
Job Title:
Employer:
Employee Classification:
Date of Hire:
Supervisor Name:
Date of Injury:
Time of Injury:
Average Hours Worked Each Day:
Average Hours Worked Each Week:
Paid For The Day of the Injury:
Yes
No
Description of Accident:
Description of Injury:
Where Accident Occurred:
How Accident Occurred:
Contributing Factors:
Witnesses:
How Could Accident Be Avoided:
Acknowledgement of Statement:
Yes
No
Person Reporting Incident:
Date Person Reported Incident:
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Peabody, Inc.
(810) 629-1504
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