Employee Accident Report Form – Prestigious Nursing

Employee Name*

First Middle Last

Phone Number*

Job Title*

Social Security Number:*

Injury Information

Date of Accident*

Time*

: Hr

Min

Specific Location of Accident*

Facility Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Description of Accident/ Injury:*

Describe what part of your body was injured:*

Describe the job you were performing at the time of injury:*

Describe what you would recommend to prevent this injury/accident:*

Additional information you would like to include regarding your injury:*

Blood Borne Pathogen Exposure?*

Yes
No

Was first aid given?*

Yes
No

Was medical attention required?*

Yes
No
Yes, but declined to seek treatment

Name of Physician*

First Last

Physician Phone Number*

Was the employee utilizing any required safety equipment?*

Yes
No

Were there any witnesses?*

Yes
No

Witness Name*

First Last

Witness Name

First Last

Employee Signature*

First Middle Last

By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this Employee Accident Form.

Acknowledgement*

I confirm that the above statements are true and correct to the best of my knowledge.

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Employee Accident Report

Injury Information

Contact

Hours