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INCIDENT REPORT FORM
•This form to be completed for alljob-related injuries or illnesses – regardless of
extent.
•Must be completed by supervisor within 24 hours of incident
•SAIF Coordinator must receive notification within 24 hours of all incidents.
IFEMPLOYEE RECEIVES MEDICAL TREATMENT OR MISSES TIME FROM WORK, A WORKERS’
COMPENSATION CLAIM - FORM 801 MUST BE COMPLETED AND SENT TO THE SAIF COORDINATOR
WITHIN 24 HOURS.
Name ________________________________________________________________Job Tile _________________________________
FirstMiddleLast
AMAM
Date of Injury:Hour:PMTime Left Work:PMDate of Birth:
Department Name
Name of Supervisor
Date Reported to Supervisor
Exact Location of Accident:
Name ofWitness:
Describe Accident (What was injured worker doing; what objects, machines o materials were involved):