Workplace Injury Form

Use this form to report any injury's or illness, that occurred while performing your duties at Affordable Assist Private Care. Please complete all sections to the best of your ability, including details about the incident, any medical care received, and witness information if applicable. Once submitted, your report will be reviewed by HR and routed for next steps.

Accident Report Form (#7)

Contact

I am reporting a work related

Today's Date

First Name

Last Name

Address Line 1

City

State

Zip Code

Email

Phone/Mobile

Date of Birth

Have you told your supervisor about this injury / near miss?

Yes

No

Incident Date and Time

Name anyone who witnessed injury or illness.

Where exactly, did it happen?

What were you doing at the time?

Please describe step by step what led up tp the injury? (Please be specific)

Could this incident been avioded?

Yes

No

What could have been done to prevent this injury?

What part of your body was or could have been injured?

Did you seek medical treatment?

Yes

No

If yes, Who did you see?

Date / Time of first visit

Doctor's phone number

Has this body part been injured before?

Yes

No

If yes, When?

Was the incident reported immediately?

Yes

No

To whom you reported too

If no, Why?

Do you have any other information or concerns that you want to share regarding this injury?