When did the injury occur?
Where did the injury occur?
Was this location the injured person'sChoose One Workplace School Home Other If "Workplace," did the injury occur as a result of employment activities? If "Other," was this a road accident? If no, did the injury occur on another's property? If yes, who owns the property? How did the injury happen?
What were the surrounding circumstances (weather, lighting, slipperiness, other)?
Were there witnesses to the injury? If yes, what are their names/contact information?
Were others involved or injured at the same time? If yes, what are their names/contact information?
Was there a police report? Did the injured person receive medical treatment? If yes, provide dates, locations, provider names, and details: Is the injured person still receiving treatment? Was the injured person killed as a result of the accident? If yes, what was the date of his or her death? Describe lifestyle changes experienced by the injured person and his or her family as a result of the accident:
Describe other losses resulting from the injury (lost wages, damaged property, other):
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