Employee Incident – Link

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Employee Incident

Employee/Witness Name*

Patient Name*

Employee/Witness Number

Date Accident took place*

Approximate time of injury

:

Specify the exact location of the accident*

Did anyone else witness the accident?*

Yes

No

Please list all witnesses*

What activity were you engaged in?*

Describe how the injury occurred*

List injured body part(s)*

Provide any other relevant information about the incident*

Employee Signature*