Date of this report:

Date of accident:

Name of employee:

Social Security Number:

Position:

Title:

Department:

Employment Commencement Date:

Number of months in this department or position:

Describe accident in detail (specify time, place, duties of employee, etc.):

Describe nature of injuries:

Names of witnesses (if any):

Have those witnesses been interviewed?  If so, by whom?

Has a written statement of all witnesses been prepared?

If so, where is the report now and who has seen it?

If not, by when?

Estimated medical consequence of accident/work injury to injured employee:

Estimated loss to Company from accident/work injury:

MANAGEMENT AUTHORIZATION

Name of Review:

Date:

Comments:

Action to be taken (specify, i.e., safety committee meeting, notify union or shop steward, replace position, etc.) and by when (specify date):