Title Page

  • Conducted on

  • Prepared by

  • Weitsman Site Location:

  • Today's Date

  • Time this report is filled out:

  • Employee's Name (First, Last)

  • Employee's Date of Birth:

  • Employee's Address:

  • Employee's Gender

  • Employee's Age:

  • Employee's Cell Phone Number:

  • Employee's Home Phone Number:

  • Employee's job description:

  • Date and Time of Accident:

  • Number of hours employee worked in the shift this accident occurred:

  • Number of hours employee worked in the week of the accident:

  • Name of Person who reported this accident?

  • Was a Weitsman-owned Vehicle Involved in this accident?

  • Vehicle Year

  • Vehicle Make/Model

  • Vehicle License Plate (State and Number)

  • Pictures taken of:

  • What does the employee report they were doing just before the injury occurred?

  • How did the injury occur?

  • Where (what part of the plant or yard) does the employee report the injury occurred?

  • Did the injury occur in an area where the employee is normally allowed?

  • List witnesses to the event and contact phone number. If there are no witnesses, list "NONE"
  • Witness Name (or None)

  • Witness Phone Number

  • Describe the injury:

  • Which side of the body did the injury occur:

  • Part of the body where injury occurred (Check as many parts as apply):

  • Describe the object or substance that caused the injury:

  • Did the employee request medical evaluation or treatment for the injury?

  • Name of Doctor, Urgent Care, or Hospital employee is going to:

  • Address or Town of Hospital:

  • Is this a hospital emergency room?

  • Was employee transported by ambulance to the hospital?

  • Was employee hospitalized overnight for inpatient treatment?

  • Is the employee's injury a fractured bone?

  • Did the employee receive stitches?

  • Did the employee lose consciousness?

  • Did the doctor prescribe a prescription medication?

  • Did the doctor advise time off of work?

  • Until what date?

  • Did the doctor advise work restrictions?

  • Can your location provide work for this employee within their medical restrictions?

  • Report prepared by (Your Name):

  • Job title of person who prepared report:

  • Telephone of person who prepared report:

  • Signature of person who prepared report:

  • Injured employee's 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. You should independently determine whether the template is suitable for your circumstances.