TOWN OF RIVERHEAD EMPLOYEE ACCIDENT REPORT
PLEASE COMPLETE AND SUBMIT TO THE ACCOUNTING DEPARTMENT
Name of injured employee: _________________________________SS#: ___________________
Home address of employee: _______________________________________________Age: _____
Job Title: _______________________Department: _______________Date of Report
Where did accident occur? _________________________________________________________
Name of Witnesses: ______________________________________________________________
Time of accident: _______________a.m./p.m.
Date of accident:
Date stopped work due to this injury: Date returned:
Nature of injury and part(s) of body affected: ___________________________________________
______________________________________________________________________________
Name and address of doctor or hospital: _____________________________________________
_____________________________________________________________________________
How did employee allegedly get injured?_____________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Was employee wearing safety equipment? Yes No
If yes what equipment was employee wearing? ______________________________________
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Immediate Supervisor signature_____________________________Date signed:
Department Head signature________________________________Date signed:
Employee signature: _____________________________________Date signed:
Employee comments: ___________________________________________________________
_____________________________________________________________________________
YOU ARE REQUIRED TO NOTIFY THE ACCOUNTING DEPARTMENT THE FIRST
DAY YOU RETURN TO WORK FROM YOUR WORKER'S COMPENSATION INJURY
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