Craft Health Employee Accident Report

Name *

First

Last

Job title *

Date and time of injury *

Date

Time

Time workday began *

City, state, zip code where injury occurred *

Please explain how the injury/accident occurred *

Describe affected body parts *

Will you be working/did you work your full schedule for the day? *

Yes
No

What could have been done differently to have prevented this injury/accident? *

I understand that by typing my name below and clicking on "Submit", I am electronically signing this document and am certifying that the above information is true and correct. *

Date *

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