SAMPLE INCIDENT/ACCIDENT REPORT FORM

- SAMPLE - FARM accident /INCIDENT REPORT form . {Farm Name}. Date of incident: _____ Time: _____ AM/PM. Weather conditions: _____. Name of injured person: Address: Phone Number(s): Date of birth: _____ Male _____ Female _____. Description of injury: _____. Details of incident: _____. _____. Were there any witnesses? Yes ___ No ___. Name of witness(es): _____ _____. Address of witness: _____. Phone number: _____. Was a witness statement obtained? Yes ___ No ___. Was first aid administered at the farm? Yes ___ No____. If yes, describe actions taken: _____. Did injury require EMS/hospital visit? Yes ___ No _____. Name of hospital: Hospital phone number: Employee investigating scene: _____. Any corrective measures taken?

Signature of injured party x_____ Date *No medical attention was desired and/or required: x Signature of injured party if medical attention declined Date

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  Form, Report, Medical, Accident, Accident report form

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