Accident 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) * Submit If you are human, leave this field blank.