Employee Accident Report

Arc Human Services - Employee Accident Report
Employee Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Employee Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employee Phone Number*
Please enter a valid phone number.
Employee Date of Hire*

MonthDayYear
Date
Days worked per week*
What time did you start your shift?

Hour Minutes

AM/PM Option
Date and Time of Accident*

MonthDayYear
Date
Hour MinutesAM/PM Option
Where did the accident happen? Please include the address if known.*
How did the accident happen?*
What part(s) of the body was involved?*
What is the body part location(s)? You may select more than one response.*

LeftRightLowerUpperMiddleBilateral (both sides)Other
Have you injured that part of your body before?*

YesNo
When and where did that injury occur? *
Was this a car accident?*

YesNo
Did you receive medical attention?*

YesNo
Are you going to seek medical attention?*

YesNo
Please be aware that if you are seeking medical attention you must be treated by a panel physician. You may find a list of appropriate physicians here -
Western Pa Panel Physicians
Dubois Panel Physicians
Name of medical provider*
Was your supervisor notified of this accident?*

YesNo
When did you report this accident?*

MonthDayYear
Date
Who did you report the accident to?*
Did you stop work as a result of the accident?*

YesNo
Do you know when you will return to work?*

YesNo
When will you return to work?*

MonthDayYear
Date
Was there a witness to the accident?*

YesNo
Number of witnesses*
Witness to the accident (1)*

First NameLast Name
Witness to the accident (2)*

First NameLast Name
Witness to the accident (3)*

First NameLast Name
Witness to the accident (4)*

First NameLast Name
Witness to the accident (5)*

First NameLast Name
Signature*

Clear
Please check your email for important information regarding your workers compensation injury.
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Arc Human Services - Employee Accident Report