Accident/Injury Report

Part 1. INJURED PERSON STATEMENT

Date of Injury (MM/DD/YYYY) *

Time (HH:MM AM or PM) *

Injured Part of the Body *

Describe the accident in detail, stating part of body injured. *

Have you had any other accidents in the Library or on Library business? *

Yes

No

If yes, when?

Occupation

Gender *

Male

Female

Where did the current accident occur? *

Name of witness if applicable

To whom did you report the accident? *

Date & Time reported (MM/DD/YYYY HH:MM AM or PM) *

Hospital and/or Doctor (include mailing address)

Date of this report (MM/DD/YYYY) *

Name of injured. And Parent/Guardian, if minor. *

Phone (Format is xxx-xxx-xxxx) *

Full Address *

Part 2. LIBRARY STAFF REPORT OF ABOVE ACCIDENT/INJURY

Nature of Injury (state injured person’s complaints and part of body) *

(Name and address of Doctor and/ or Hospital)

Staff member’s name, if different from “To Whom report” above *

Date & Time Completed (MM/DD/YYYY HH:MM AM or PM) *