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? Yes No If "Other," was this a road accident? Yes No If no, did the injury occur on another's property? Yes No 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? Yes No If yes, what are their names/contact information?
Were others involved or injured at the same time? Yes No If yes, what are their names/contact information?
Was there a police report? Yes No Did the injured person receive medical treatment? Yes No If yes, provide dates, locations, provider names, and details: Is the injured person still receiving treatment? Yes No Was the injured person killed as a result of the accident? Yes No 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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