Description of Accident (Provide a summary of incident, include specific body part injured, nature of injury, weather conditions, etc. Also describeclothing worn, any medical or ambulatory devices used by customer.)
Description of Accident Location (Exact location where the accident/incident occurred, upload photo(s) below if necessary.)
What was this person doing at the time the event occurred?
Slip/Trip/FallAnimal Bite/StingDehydrationStruck by ObjectChemical IrritationAuto/VehicleAssaultHeat BurnPlant/ProductOther (describe)
Corrective Actions Comments:
** File Size Limit - 5 MB For files larger than 5 MB indicate location on our server or send in a separate email with the work order referenced.