GoodwillJax Accident/Incident Report

• Location

• Conducted on

  Date
• Address
  Address

• Is the injured an employee or non-employee?

  Employee

  Non-Employee

Employee

• Name of Injured:

• Phone#:

• Address of injured:
  Address

• Describe injury or property damage

• Please attach any photos here

  Media

• Describe accident/incident and how it occurred:

• Witnesses:

• Date and Time of accident/incident:

  Date

• Medical attention provided to injured?

  Yes

  No

• Please immediately contact Andre' Tarrance @ 904-412-8317, or your direct supervisor for a medical referral and instructions.
  

• If medical attention is needed later, then you must first contact your direct supervisor or Andre' Tarrance @904-412-8317 prior to seeking medical attention. A claim and referral must be created prior to seeking medical treatment.
  

• Please have employee sign

  Sign

Non-Employee

• Name of Injured:

• Phone#:

• Address of injured:
  Address

• Sex:

  Male

  Female

• Describe injury or property damage.

• Please attach any photos here

  Media

• Describe accident/incident and how it occurred:

• Were there any goods or equipment that caused the accident? I.e. Broken chair

  Yes

  No

• Please verify that the item is in the managers office.

• Please attach photo of item.

  Media

• Witnesses:

• Date and Time of accident/incident:

  Date

• Is the injured individual 18 or older?

  Yes

  No

• Please provide the name of the parent or guardian.

• What is the age of the injured?

• Medical attention above general first aid provided to injured?

  Yes

  No

• Please immediately contact Andre' Tarrance @ 904-412-8317

• Comments:

• Prepared by:

  Sign

• Title: