Employee Information

  • Employee Name:

  • Address:

  • Street:

  • City:

  • State:

  • ZIP Code:

  • Social Security Number:

  • Date Of Birth:

  • Contact Number:

  • Marital Status:

  • Number of Dependents Under 18:

  • Date of Hire:

  • Wages:

  • Employee Occupation:

Accident Information

  • Incident Date:

  • Incident Time:

  • Date Reported To Employer:

  • Activity Engaged In:

  • Accident Description:

  • Please attach photos as necessary

  • Is there a reason to doubt the validity of the claim? (If yes, please explain):

  • Was employee performing regular duties?

  • Did the incident occur on premises? (If no, provide location)

  • Street:

  • City:

  • State:

  • ZIP Code:

  • County:

  • Did another person cause the accident? (If yes, name of person)

  • Please attach photos as necessary

  • Are there any witnesses? (If yes, name of witness)

  • Was there a police report filed?

  • Name of Police Department:

  • Report Number:

  • Phone Number:

  • Was Cal-OSHA notified of the incident?

  • District Office Location:

  • Street:

  • City:

  • State:

  • County:

  • Office Phone Number:

Injury Information

  • Part of the body injured:

  • Nature of injury:

  • Cause of injury:

  • Attach photos as necessary

  • First Aid Only?

  • Recordable?

  • Is employee losing time? (If so, date began)

  • Date of lost time:

  • Number of lost days:

  • Employee return to work? (If so, date returned to work)

  • Date returned to work:

  • Employee paid for date of accident?

  • Was safety apparatus provide?

  • Was safety apparatus used?

  • Safety apparatus description:

  • Attach photos as necessary

Provider Information

  • Medical treatment rendered?

  • Under active medical care?

  • Medical Provider Name:

  • Phone Number:

  • Street:

  • City:

  • State:

  • ZIP Code:

  • Additional Comments:

  • Attach photos as necessary

  • Report Conducted By:

  • Add signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. Any ratings or scores displayed in our Public Library have not been verified by SafetyCulture for accuracy. Users of our platform may provide a rating or score that is incorrect or misleading. You should independently determine whether the template is suitable for your circumstances. You can use our Public Library to search based on criteria such as industry and subject matter. Search results are based on their relevance to your search and other criteria. We may feature checklists based on subject matters we think may be of interest to our customers.