Accident/Injury Employee Report

Report Date*

Date of Accident/Incident*

If Report Date is AFTER the actual Date of Accident/Incident, please explain why it was not reported on the same day. (If Report Date & Accident/Incident Date are the SAME, enter N/A in the response box.)*

Time Employee Began Work on Date of Accident/Incident*

:

Time of Accident/Incident*

:

Accident Location Information

Location of Accident*

Description of Area Where Accident Took Place*

Name of Employee Reporting Accident*

First Last

Title of Employee Reporting Accident*

Phone of Employee Reporting Accident*

Email of Employee Reporting Accident*

Person Injured Information

Name of Person Injured*

First Last

Phone of Person Injured*

Email of Person Injured

Accident/Incident Details*

Hospitalization Required?*

Yes
No

If taken to the hospital, how was the person transported?

Ambulance
Long-Lewis Employee
Family Member/Friend

Witness Information

Name of Witnesses 1

First Last

Phone of Witnesses 1

Email of Witnesses 1

Name of Witnesses 2

First Last

Phone of Witnesses 2

Email of Witnesses 2

Name of Witnesses 3

First Last

Phone of Witnesses 3

Email of Witnesses 3

If More Than 3, Please List Here

Additional Information/Details

Upload Photos/Supporting Documentation

Accepted file types: jpg, tiff, pdf, doc, docx, xls, xlsx, Max. file size: 50 MB.

If you would like to upload photos and/or supporting documents, please do so above. Acceptable file formats are jpg, tiff, pdf, doc, docx, xls, xlsx.

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Accident/Injury Employee Report

This electronic form MUST be completed by a Manager immediately following notification of an Employee Injury/Incident, regardless of how small or insignificant the injury/incident.

Drug Screen Required

Workers’ Comp/Drug Screen Designated Facilities

If the injury warrants an ambulance, call 911 first.