Information
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Audit Title
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Date of Report
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Date of Accident
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Site & Job Number
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Employee Full Name
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Employee Social Security Number
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Employee Number
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Age
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Date of Birth
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Occupation
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Length of Employment with IME?
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Date and time of accident
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Enter last day worked if not still working for IME
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Date and time you notified your supervisor?
Accident Information
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Enter description of accident
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Enter in detail the activity when accident occurred
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Enter where you went for medical treatment
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Address and phone number of medical provider
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Name of Doctor
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Describe in detail what medical treatment you recieved
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Add media
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Add drawing
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List any witness in the area
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Employee Name
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Employee Signature
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Supervisors Name
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Supervisors signature
Statements
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Employee Statement
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Add drawing
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Witness Full Name
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Witness Statement
