Accident/Injury Report Form

Employee completes the first form. 

Supervisor completes the form closer to the bottom of the page.

Employee:

  • Instructions for Employees

    All employees are required to report all injuries/accidents 1) Contact the Department of Public Safety immediately. 2) Notify your supervisor as soon as possible.
  • Complete the “ACCIDENT/INCIDENT Employee Statement” form (SGWCP-2) below and submit within 48 hours of incident.

  • NOTE: Under the N.C. Workers’ Compensation Act, the EMPLOYER chooses the physician/hospital for employee care. An employee’s failure to utilize an employer-directed physician could result in non-payable charges associated with the unauthorized provider and the employee will be responsible for subsequent expenses.

  • MM slash DD slash YYYY
  • :
  • MM slash DD slash YYYY
  • Be as specific as possible.
  • Be as specific as possible.
  • Be as detailed as possible.
  • List anyone who may have witnessed to accident/incident.
  • Drop files here or
    Accepted file types: jpg, gif, png, pdf, doc, Max. file size: 49 MB, Max. files: 5.
    • I understand the information above will be used by my employer to help determine liability for the injury. I acknowledge that the above statement is a true and accurate representation of this information.

    • By submitting this form electronically, you are giving consent to use this as acknowledgement of your electronic signature.

      This will be utilized in place of your handwritten signature.

     


    Supervisor:

    • Alamance Community College Worker's Comp

    • Instructions for Supervisors

      1. Contact the Department of Public Safety immediately.
      2. If medical treatment is required, direct or facilitate transfer of employee to go to one of the facilities listed on the employee statement form.
      3. Complete the “ACCIDENT/INCIDENT Investigative Form,” within 48 hours of incident.

      Reminder: Under the N.C. Workers’ Compensation Act, the EMPLOYER chooses the physician/hospital for employee care. An employee’s failure to utilize an employer-directed physician could result in non-payable charges associated with the unauthorized provider and the employee will be responsible for subsequent expenses.
    • If more than one employee injured, complete a separate incident form for each injured employee.
    • MM slash DD slash YYYY
    • :
    • MM slash DD slash YYYY
    • Be as specific as possible.
    • (What happened?) Be as detailed as possible.
    • (What caused it to happen?) Be as detailed as possible.
    • Person responsible for corrective action:
    • Max. file size: 49 MB.
      Upload any email's/correspondences, photos relative to incident.
    • I acknowledge that the above statement is a true and accurate representation of the information provided to me by the injured employee. By submitting this form electronically, you are giving consent to use this as acknowledgement of your electronic signature.