Employee Incident/Accident Report 3-Part Form

Part 1 of this form captures the data necessary to adequately evaluate all accidents and incidents in order to determine what (if any) action needs to be taken. Parts 2 and 3, however, are designed specifically as the communication link between your facility/ agency and the health care professional in the event that medical help must be sought. The top portion of Parts 2 and 3 record all of the information about the incident you are required to submit to the health care provider. The lower portion allows him/her to report back to you. All information requested about an exposure incident is conveniently printed in red ink.