Laserfiche WebLink
VIA <br />Employee's Report of Accident /INJURY <br />Bus Employee s name Age Sex <br />Job position/title Social Security number <br />Shift hours Days oft Supervisor's name <br />Date and time of accident Location <br />-(in j ury ) <br />Task being performed when accident occurred <br />Date, tune acct ent zYeported To whom? <br />Date, time you first sought medical attention <br />Name of doctor and/or hospital <br />Could anything be done to prevent a(cciNen of this type? If so, what? <br />Signatum of employee Date <br />Name(s) of witness(es) <br />mom <br />(injury) <br />Describe how the accident occurred <br />t <br />What part of the body was injured <br />r <br />Desc foe the injuries in detail <br />Date, time you first sought medical attention <br />Name of doctor and/or hospital <br />Could anything be done to prevent a(cciNen of this type? If so, what? <br />Signatum of employee Date <br />