Form 4020

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1. Name of Injured Employee:

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2. Position/Job Title (at time of accident)

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3. Length of Time in that Position

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4. Location of Incident (include address)

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5. Location of Accident (choose one)

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6. Shift Being Worked (choose one)

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7. Date & Time of Accident

Date
Time

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8. Date & Time Reported to Employer:

Date
Time

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9. Name of Person the Accident Was Reported to:

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10. Was Outside Medical Attention Obtained?

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11. If 'Yes' to Q10, name and address of medical facility used:

Questions 12 - 18 - (Field A through Field G)
Please select the best possible answer that describes the situation/injury being detailed on this report.  If needed, add additional details in the 'Other' section comment boxes. 

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12. Field A - Class of Injury (indicate unknown if needed)

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13. Field B - Affected Injury Site (check all that apply)

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14. Field C - Type of Accident

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15. Field D - Accident Source

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16. Field E - Unsafe Condition

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17. Field F - Unsafe Action

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18. Field G - Organizational Problems

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19. Provide a description of the accident as detail by the injured employee.  ie:  What happened?  What is the injury?  What cause the injury?  

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20. What is the corrective measure proposed by the injured employee to help prevent this from happening in the future?

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21. Report completed by:

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22. I acknowledge the information in this survey is complete to the best of my recollection.

Next Steps:
- Supervisor to complete the After Accident Investigation Report

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