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Goodland Regional Medical Center

GRMC Employee Report of Accident

An employee who is injured on the job is to notify their supervisor within 24 hours and
complete the "Report of Employee Accident" form within 10 days of the incident.
Submit electronically to Human Resources. Print completed and signed form and give to department manager.
* Employee Name:
* Date of Birth
* Age
* Last 4 Digits of SSN
Last 4 Digits of SSN
* Gender: Female
Male
* Home Address
* Home phone
* Employee's Occupation
* Department:
* Job Title:
* On Duty?: Yes
No
* Date of Injury:
* Time of Injury:
* Date reported to employer:
* Location of Accident:
* Was accident or last exposure on employer's premises? Yes
No
* How did accident occur?
* What was employee doing when injured?
* Name substance or object that directly caused injury:
* Describe in detail nature and extent of injury, indicate part of body involved:
* Was employee admitted to hospital? Yes
No
  Date employee admitted to hospital if applicable:
  Teated by emergency room only? Yes
No
  Hosptial name and address:
  Name and address of attending physician or clinic:
  Has employee returned to regular duty? Yes
No
  Date returned to work if applicable:
  Light Duty? Yes
No
Witnesses
Please list other employees involved or who witnessed accident.
  Name:
  Job Title:
  Name:
  Job Title:
Exposure Report
If incident was a result of blood or body fluid exposure, please print out Exposure forms.
  Comments:
  Employee Signature:
  Date Report Done:
  Human Resources Signature:
  Date: