Accident Report Form

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Due if an employee sustains an injury while working on a jobsite, in accordance with the requirements of the CBA

1 Employer Information

Employer:

Employer Number:

Contact Name (Owner, Supt, Project Mgr):

Contact Email Address:

Contact Phone Number:

Employer Address:
Please select proper location address from the dropdown options

Street Number:

Street Name:

City:

State:

Zip Code:

County:

Submitted By:

2 Jobsite Information

New Construction?

YesNo

Client or General Contractor:

Jobsite Name:

Property Owner:

Jobsite Address:
Please select proper location address from the dropdown options

Street Number:

Street Name:

City:

State:

Zip Code:

County:

Jobsite Supervisor Name:

Craft:

Job Type:

Public/Private:

Floor, Suite, Apt or Lot #:

Notes:

3 Employee Information

Employee Name:

Local Number:

Received Medical Care?

YesNo

Date of Accident:

Time of Accident:

Witness:

Notes:

Add new employee

Painters district council 14