WHAT SUGGESTION DO YOU HAVE TO CORRECT THE SITUATION? DATE:_____________ NAME OF EMPLOYER MAKING THE REPORT:_____________________________________ Accident Prevention Plan Accident Report AGENCO Company Name: Date of Injury: Job Site Name: Date Accident Reported: Name of Injured Employee: Address of Employee: Telephone Number: Date of Hire: Social Security Number: Male Female Occupation of Employee: Date of Employee Works _______ Hours Per (circle) DAY WEEK Paid for Day: YES NO Time of Injury: Gross Wage Per Hour/Salary: Who Was Injury Reported To? Date: Type of Injury: Part of Body: Which Side? Witness(es) To the Accident: How Did The Accident Happen? What Caused the Accident (uneven ground, saw, etc) Where on the Job Site did the Accident Happen? Was the Employee Wearing the Proper Safety Equipment? YES NO What Type? Name of Medical Facility Employee Taken: Last Day Employee Worked: Modified Duty Offered? YES NO Did Employee Accept the Modified Duty and if NO, why Not? Date Employee Returned to Work: Time: ____________AM ___________ PM Name of Person Completing this Form? Date: Name of Employees Supervisor? Supervisors Signature: Date:
WHAT SUGGESTION DO YOU HAVE TO CORRECT THE SITUATION? DATE:_____________ NAME OF EMPLOYER MAKING THE REPORT:_____________________________________ Accident Prevention Plan Accident Report AGENCO Company Name: Date of Injury: Job Site Name: Date Accident Reported: Name of Injured Employee: Address of Employee: Telephone Number: Date of Hire: Social Security Number: Male Female Occupation of Employee: Date of Employee Works _______ Hours Per (circle) DAY WEEK Paid for Day: YES NO Time of Injury: Gross Wage Per Hour/Salary: Who Was Injury Reported To? Date: Type of Injury: Part of Body: Which Side? Witness(es) To the Accident: How Did The Accident Happen? What Caused the Accident (uneven ground, saw, etc) Where on the Job Site did the Accident Happen? Was the Employee Wearing the Proper Safety Equipment? YES NO What Type? Name of Medical Facility Employee Taken: Last Day Employee Worked: Modified Duty Offered? YES NO Did Employee Accept the Modified Duty and if NO, why Not? Date Employee Returned to Work: Time: ____________AM ___________ PM Name of Person Completing this Form? Date: Name of Employees Supervisor? Supervisors Signature: Date:
AGENCO_SAFETY_PLAN.docx