Accident Report

Last Name *

First Name *

Penn State Id *

Email *

Work Phone

Cell Phone

Home Phone

Type of Employee (faculty, staff, tech service, wage)

How many hours does employee work? *

What time did he/she begin work on the day of the accident? *

Date Injury Occurred *

Time Injury Occurred *

Where did the injury occur? *

Building, room number, address, etc.

Describe how and where the injury occurred and what activity you were performing when the injury occurred *

(include specific details if any equipment or tools or safety equipment were used, etc.)

Describe the nature and location of the injury to the body *

(example: head, neck, left arm, right arm, left leg, right leg, etc.)

If this is a hand/arm injury, do you know if they are right or left handed and can they perform their tasks with this injury? *

Did the employee lose any time as a result of the accident? *

Yes

If so, list days or hours missed

Was any safety equipment used or provided? *

Did the employee need to be taken to a hospital or seek other treatment after the injury? *

Yes

If so, please list where the employee went (name and address), name of attending physician, etc

Were there any witnesses? If so, please list name(s) and contact phone number(s)