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Accident Investigation Report Form EMPLOYEE DETAILS Name: Position: Address: INJURY DETAILS Date of accident: Time: Date Reported: Time: Date ceased work: Time: Supervisor: Time lost (to date): Time lost (anticipated overall) Medical Treatment required: Nature and extent of injury Part of body injured Head Trunk Multiple Eyes Arm General Neck Leg Unspecified Nature of injury Sprain Laceration Burn Fracture Concussion Superficial Multiple Dislocation Amputation Contusion Other Type of incident Flying object Manual handling Electricity Struck by Poisons Fall Caught in Temperature Other Describe the events leading up to the injury and how the injury occurred (witness or injured person s statement)..