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DAMES & MOORE <br /> ACCIDENT REPORT FORM <br /> Employee Name Date of birth <br /> Home Address Phone <br /> Sex: ❑Male ❑ Female Job Title Social Security No <br /> Office No. Office Location Date of Hire <br /> Hours Usually worked: Hours per day Hours per week Total hours weekly <br /> Where did accident or exposure occur? (Include address) <br /> County On employer's premises? ❑ Yes ❑ No <br /> What was employee doing when injured (Be specific) <br /> How did the accident or exposure occur? (Describe fully) <br /> What steps could be taken to prevent such an occurence? <br /> Object or substance that directly injured employee <br /> Describe the injury or illness Part of body affected <br /> Name and address of physician <br /> If hospitalized, name and address of hospital <br /> Date of injury/illness Time of day Loss of one or more day of work? ❑yes ❑no <br /> If yes, date last worked <br /> Has employee returned to work? If yes, date returned Did employee die? ❑yes ❑no <br /> If yes, date of death <br /> Completed by (Print name) Signature <br /> Title Date <br /> An Accident/exposure report must be completed by the supervisor or site safety officer immediately upon learning of <br /> the incident. The completed report must be immediately transmitted to the office administrative manager and the <br /> Division Health and Safety Manager. <br />