Township of Lakewood - OCJIF

ACCIDENT INVESTIGATION REPORT

Immediate completion assists employees in obtaining workers' compensation benefits.

Today's Date

Department

Time

First Name

Last Name

Date of Birth

Home Address

Phone #

Last 4 of SSN

Sex

Complete Description of Accident:

1. Do you usually supervise this individual?

Yes No

2. Was accident immediately reported?

Yes No

4. At work on company time?

6. Any unsafe conditions/hazards?

10. Provided safety equipment in use?

FormFlow