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Complete this form to report an accident. After the form is completed, print a copy for your safety coordinator. By submitting this electronic Accident Report, you are not required to submit a hardcopy to Human Resources.

Employee ID*
Today's Date*
Employee First Name*
Employee Middle Name
Employee Last Name*
Employee Address*
Phone Number*
Gender*
Date of Birth*
Marital Status*
Number of Dependent Children*
Department*
Date Reported to Employer*
Date of Injury*
Hour of Injury*
Location Where Accident Occurred
Occupation at Time of Injury or Illness*
Person to Whom Reported*
Name of Other Witness
How Long in Current Job?*
How Long With Current Employer?
Hours Worked Per Day*
Days Worked Per Week*
Wages Per Hour
Earnings Per Week

Machine, tool or object causing injury or illness

Specify part of machine, etc.

Describe fully how injury or illness occurred*

Describe nature or injury or illness, including parts of body affected*

Physician Name
Physician Address
Hospital Name
Hospital Address
Probable Length of Disability*
Has employee returned to work?*
> If yes, at what wage?
> On what date?
Where did accident occur?
Was safety equipment provided?*
> If yes, was it used?

What suggestions do you have to prevent this accident from happening again?

Comments

Place a check in each of the boxes below indicating that you have read the given statement.

I understand I am required to choose a physician from our panel at the time I report my accident/illness (statement one).*

Place a check in the box below indicating your choice of physicians. If you choose not to be treated by a Panel Physician, you risk losing Workers' Compensation benefits.

I understand that by marking one of the boxes below, I am indicating my choice of Panel Physicians (statement two).*

RMH Occupational Health Center
Dr. Stephen Phillips
1790 Suite 64B E. Market St.
Harrisonburg, VA 22801
(540) 564-5622

  Carilion Clinic
Dr. Ronald Schubert
Dr. Michael Marsh
Dr. Robert Pence
15 Killdeer Lane
Dayton, VA 22821
(540) 879-4300

 EmergiCare
Dr. Rick Stough
755 Cantrell Avenue
Harrisonburg, VA 22801
(540) 432-9996

Note: JMU Staff Physicians are no longer participating with the panel

  I am seeking medical treatment at this time.*

I am not seeking medical treatment at this time, however, I understand that if medical treatment becomes necessary in the future, I may see the physician that I have selected above (statement three).

By typing the injured person's name in the box below, I understand that I am reporting an accident. The information submitted via this form is true to the best of my knowledge (statement four).*

Name of Person Submitting Form:

* indicates a required field