Employee Accident Report (To Be Completed by the Injured Employee) "*" indicates required fields Store Location*- Select Location -Smyrna, GAAtlanta, GAJonesboro, GACollege Park, GAFairburn, GARiverdale, GAPonce de Leon, GANorman West, OKMoore, OKWarr Acres, OKReno, OKStillwater, OKRockwell, OKYukon, OKMidwest City, OKMustang, OKManager's Email* Employer*Employee Name* First Last Date of Accident* MM slash DD slash YYYY Location of Accident**WHAT HAPPENED? (PLEASE DESCRIBE ACCIDENT ON YOUR OWN WORDS):*HOW WERE YOU INJURED?*WHAT PARTS OF YOUR BODY WAS/WERE HURT? (Indicate right or left)*HAVE YOU EVER INJURED THIS PART OF YOUR BODY BEFORE?* Yes No If yes, please describe:WHO WAS PRESENT WHEN THE ACCIDENT/INCIDENT HAPPENED?*THE ABOVE IS TRUE AND CORRECT* Yes No Signature*Date* MM slash DD slash YYYY ACCIDENT REPORTS MUIST BE HANDED IN TO YOUR SUPERVIOSR OR ACTING SUPERVISOR IMMEDIATELY AFTER ANY ACIDENT. FAILURE TO PROMPTLY REPORT ACCIDENTS WILL RESULT IN DISCIPLINE UP TO AND INCLUDING DISCHARGE. Willingly making a false statement for the purpose of obtaining or denying benefits is a crime subject to penalties up to $10,000 per violation.
