Employee/Visitor Accident Report
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Email *
Person Submitting Report  *
Select the principal of the school where incident occurred and/or employee works. *
Required
Injured Person's First Name *
Injured Person's Last Name *
Injured Person's Home Address (123 Sesame St, New York NY 99999)
Injured Person's Phone Number (xxx-xxx-xxxx)
Injured Person's Email Address *
Number of Dependents  *
Date of Incident *
MM
/
DD
/
YYYY
Time of Incident *
Time
:
Location of Incident - be specific *
Last date worked - if not an employee, put incident date *
MM
/
DD
/
YYYY
Date returned to work - if not an employee, put incident date *
MM
/
DD
/
YYYY
Time the employee began work on the date of the incident or time the visitor came to campus *
Time
:
Were safeguards or safety equipment provided *
Were they used?  *
Degree of Injury *
Nature of Accident (mark all that apply) *
Required
If "Other", please describe...
Part of Body Injured (mark all that apply) *
Required
Side of body if applicable... *
Required
All equipment, materials, or chemicals injured person was using when incident or illness exposure occurred:  *
Specify the activity the injured person was engaged in when the incident or illness occurred: *
Work process the injured person was engaged in when incident or illness exposure occurred: *
How incident or illness/abnormal health condition occurred. Describe the sequence of events and include any objects or substances that directly injured the person or made them ill: *
Witness Name *
Witness Phone Number *
Was the injured person taken to the doctor or hospital before this report? 

Report later medical treatment to crystal.claar@fairview.kyschools.us if it occurs after this report. 
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