EmailMe Form - Investigation Report for Work Related Injuries

Check Type of Accident
Auto Accident
Customer Behavioral Incident
General Accident
Lifting Accident
Slip/Fall Accident
List Customer Name
Employee Name
Gender
Male
Female
Employee Social Security Number
Employee's Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Date of Birth
Date of hire
Job Title
What office location are you an employee of:
Program Manager or Lead Program Manager's Name:
Employee's Phone Phone:
Time arrived on shift:
Date of Accident
Time of Accident
Place of Accident:
(list physical address)
Location of Accident (bedroom, kitchen, etc...)
Witness
Date and name of Supervisor notified
How long have you worked with this individual
Are you fully trained to work with this individual
If no, what classes/in-services do you need
How many hours did you sleep last night
Was it consecutive
When was your last shift/job
Describe injuries (list body part injured)
How did injury occur
Describe what you were doing immediately before the accident/injury
If customer caused injury, Describe what the customer was doing BEFORE, DURING, and AFTER the incident.
Did you leave work before your scheduled shift was over:
What time did you leave
Did you request treatment at the time of injury.
Did you refuse treatment at the time of injury
If refused, why
Staff Signature
Clear
Date