Employee Report of Accident or Incident (FDSS)

Incident/Accident Report

Completed by FDSS Employee
This form is to be completed by the injured party, in your words to the best of your recollection. Please be as detailed as possible. Attach any documentation via the upload button below. You will be contacted if there are additional questions or more information is required.
Date

MonthDayYear
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
FDSS Division
This is a report of (check all that apply):

Other
Your name:

First NameLast Name
Your email address:
example@yahoo.com
Your supervisor's email address:
If you don't know, you can leave this blank.
The job/company you were working for at the time of the incident:
Date the incident/accident occurred:

MonthDayYear
Date the incident/accident occurred:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Did you miss any days of work?
Date you returned to work (if you missed any days):

MonthDayYear
Time of incident/accident:

Hour Minutes

AM/PM Option
Where/what part of the work environment did the incident/accident occur?
What is license number of the vehicle:
What is the make/model of the vehicle:
Detailed description of the incident/accident:
What part of the body was injured (if there was an injury)?
Did you go to the doctor or hospital?
Hospital/Clinic Info
Were police involved?
During what part of your workday did the incident occur?
Describe the location/environment at the time of the incident/injury:
Where did it occur, what was the weather like if that was a contributing factor, was it messy, hot, icy, noisy, etc.
Were you aware of safety regulations, and if "no" what went wrong/what changes would you suggest?
Witnesses
Upload any supporting documents:

Cancelof
Take Photo
My signature below indicates that this is a truthful representation of the facts surrounding this incident. I also acknowledge that should it become apparent (through investigation, legal procedings, or other mechanisms) that I have misrepresented the facts, I will be subject to disciplinary action up to and including termination.
Signature
Should be Empty:

Incident/Accident Report