SAMPLE INCIDENT/ACCIDENT REPORT FORM
Accident/Incident Report Form
Date of incident: _______________ Time: ________ AM/PM
Name of injured person:
Address:
Phone Number(s):
Date of birth: ________________ Male ______ Female _______
Type of injury:
Details of incident:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Witnesses/Employees Who Assisted: _______________________________________________
Injury requires physician/hospital visit? Yes ___ No _____
Name of physician/hospital:
Address:
Physician/hospital phone number:
Result from Physician/hospital visit: ________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Signature of injured party _________________________________________________________
Date
*No medical attention was desired and/or required.
Signature of injured party Date
................
................
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