Form 4020

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1. Today's Date:

Date

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2. This report is in relation to the accident/injury related to employee:

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3. The accident/injury date was:

Date

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4. Location of Original Incident (include address)

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5. Provide a brief recap of the accident/injury that occurred:

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6. Provide a description of the after accident investigation that occurred:

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7. What corrective actions have been proposed and discussed?

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8. Who has responsibility to ensure corrective actions have been properly deployed?

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9. Are there any outstanding issues related to this accident/injury that need to be reviewed?

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10. This report has been completed by:

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11. I certify the information provided is complete and accurate

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12. Is there any additional information to add?

T