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Online Accident Report

The affected employee is to complete this form and submit immediately after incident (no more than 12 hours after incident). Note: If the affected employee is unable to submit this report, the Regional or Department Manager is responsible for submitting this report.

This form is designed for use with MS Internet Explorer.

When you have completed all information, read the statement at the end of the form and press the Submit Form button.

*Indicates required field.

  1. *Incident Date:   

  2. *Where incident Occurred:

    • If "Other" selected, enter where incident occurred:

  3. *Select Equipment Type:

  4. Materials, or Chemicals Employee was Using When Event or Exposure Occurred:

  5. *Specific Activity Employee was Performing When Event or Exposure Occurred (Robot Maint,  Walking on Stairs, etc.):

  6. *How Incident Occurred. Describe Sequence of Events. Specify Object or Exposure Which Directly Produced the Injury/Illness. Be very specific and detailed in your description:
     

  7. *Employee Name: Address: Phone:

  8. *Employee's Department:

    • Other Department:

  9. *Employee's Shift:

  10. *Date Last Worked:

  11. *Employee Unable to Work For At Least One Full Day After Injury?

  12. *Date Returned to Work:  

  13. *Other Workers Injured in this Incident?

  14. *Manager Name:

  15. Comments:
     
     

Complete the following section if the incident resulted in any type of injury or illness, no matter how minor:

  1. Specific Injury or Illness: 

  2. Part of Body Affected:  

    • Other:

  3. Did you, or do you expect to, receive any type of medical care beyond first aid? (see definition of *First Aid below)

  4. Workers Compensation Information:

    • If you received medical care, a Workers Comp claim is required and a claim will be filed on your behalf by the Safety Manager.

    • *You have the right to file a Workers Compensation claim for any work-related injury, even if you do not receive medical care.  Please indicate your wish concerning filing a Workers Comp claim:

      • Note: Workers Comp laws are different in each state. Some states permit an injured worker to file a claim up to one year after an injury. Visit the  Workers Comp Information Page to learn more about the Workers Comp system in your  state.

Confirmation: You will be sent to a Confirmation Page after selecting the Submit Form Now button.

By pressing the "Submit Form Now" button, I certify that all of the information submitted on this form is accurate and correct. To the best of my knowledge, no false statements or misrepresentations are made in this  report.

   

*First aid refers to medical attention that is usually administered immediately after the injury occurs and at the location where it occurred. It often consists of a one-time, short-term treatment and requires little technology or training to administer. First aid can include cleaning minor cuts, scrapes, or scratches, treating a minor burn, applying bandages and dressings, the use of non-prescription medicine, draining blisters, removing debris from the eyes, the use of massage, and drinking fluids to relieve heat stress..