Get Employee Report Of Accident/injury Form - Ncdhhs

Filling out the Employee Report Of Accident/Injury Form is crucial for ensuring proper documentation following an accident or injury. This guide provides clear, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to complete the report online.

1. Click ‘Get Form’ button to access the report and open it in the editor.
2. Enter your name in the designated field. This ensures you are identified as the person reporting the accident or injury.
3. Fill in the date of the injury. It is important to be as precise as possible regarding when the incident occurred.
4. Provide your Social Security number, which may be required for processing the report.
5. Indicate whether you are a full-time or part-time employee by selecting the appropriate option.
6. Record the time of the injury and select either AM or PM to accurately reflect the time it occurred.
7. Input your date of birth for identification purposes.
8. List your work phone number for any follow-ups regarding the report.
9. Enter the date you were employed, which helps to establish your duration of service.
10. Specify your department or division to provide context about your work environment.
11. Provide your home phone number and address to ensure you can be contacted if necessary.
12. Select your shift (A, B, C) to clarify which work period you were in.
13. Indicate the start time of your workday to provide context for the incident.
14. List any witnesses to the incident and attach statements from each if available.
15. Describe the exact location where the injury occurred to give clarity on where the incident took place.
16. Detail the specific duties you were performing at the time of the injury.
17. Describe the circumstances leading to the injury thoroughly to give context to your report.
18. Select the personal protective equipment you were using at the time of the injury, if any.
19. Identify the object, equipment, or substance that caused the injury to clearly state what was involved.
20. Choose any factors that contributed to the accident occurring from the provided options.
21. Specify the nature of the injury by selecting the relevant body parts affected and provide additional details where necessary.
22. Indicate the type of medical treatment received, if applicable.
23. Sign the form to verify that the information you have provided is accurate.
24. Obtain your supervisor's signature and title to finalize the report.
25. Once all sections are complete, you may save your changes, download a copy of the report, print it, or share it as required.

Start filling out your Employee Report Of Accident/Injury Form online today.