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.Format: (000) 000-0000.
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.

Other
Have you injured that part of your body before?
When and where did that injury occur?
Was this a car accident?
Did you receive medical attention?
Are you going to seek medical attention?
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?
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?
Do you know when you will return to work?
When will you return to work?

MonthDayYear
Date
Was there a witness to the accident?
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
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Arc Human Services - Employee Accident Report