Home > Employee Report of Injury/Accident Today's Date (required) Time (required) Name (required) Date of Accident (required) Injury (required) Treatment (required) By Whom (required) Supervisor or Manager (required) Accident Description (What happened in your words) Who, What, When, Where, How, & Why? (required) In your opinion, what caused the Accident/ Injury? (required) Describe any unsafe conditions (required) I certify that the above information to be true and correct with no omissions (required) I agree Signature of Employee (required) Date (required) Get in Touch With Us Fill out the form below and click Send to contact us 24/7. We'll get back to you as soon as possible. Name Please enter your name. Subject Please enter a subject. Email Please enter a valid email. Phone Please enter a valid phone number. Your Message Please enter a message. Send Message failed. Please try again. Thanks for your message! We’ll be in touch soon.