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Employee Injury Form (Employee’s Form)

Employee Injury Form (Employee’s Form)

In the event of an employee accident/injury the following report/forms are required to be completed within 48 hours.

Injured Employee is to complete the form below.

Employee Injury/Accident Statement Form

Complete this form within 48 hours of incident.

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.

Employees are to go to a Fast Med Urgent Care location and present this form:

Download the Required Form here (PDF)
Public Safety Notified? * Required
- YES
- NO
Injured Employee Name * Required
First Last
Department
Date of Injury/Accident * Required
MM slash DD slash YYYY
Time of Injury/Accident

: Hours

Minutes

AM/PM AM/PM
Supervisor Notified? * Required
- YES
- NO
Name of Supervisor Notified of Injury * Required
First Last
Date Injury Was Reported * Required
MM slash DD slash YYYY
Weather conditions at time of incident: * Required
- Daytime, Sunny, Dry
- Daytime, Cloudy, Dry
- Daytime, Cloudy, Raining, Wet
- Night-time, Dark, Dry
- Night-time, Lighted, Dry
- Night-time, Lighted, Raining, Wet
- Day-time, Snowing
- Day-time, Freezing Rain
Location of Incident
Be as specific as possible.
Part of Body Injured * Required
Be specific and detailed.
Description of Accident: * Required
Be as detailed as possible.
Was Medical Assistance Administered? * Required
- YES
- NO
- TRANSPORTED BY E.M.S TO HOSPITAL
- TRANSPORTED THEMSELVES TO ABOVE INDICATED MEDICAL FACILITY
- REFUSED MEDICAL ATTENTION
Are there any witnesses to the accident/incident? If yes, who?
List anyone who may have witnessed to accident/incident.
Cause of Accident:
Upload any files pertaining to this accident/injury.
Drop files here or

Max. file size: 49 MB.
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.

Alamance Community College

MAIN CAMPUS 1247 Jimmie Kerr Rd. • Graham, NC
P.O. Box 8000 • Graham NC, 27253-8000
PHONE: (336) 578-2002
FAX: (336) 578-1987

DILLINGHAM CENTER 1304 Plaza Drive • Burlington, NC 27215
PHONE: (336) 506-4300
FAX: (336) 506-4342

Proudly serving our community since 1958

MAIN CAMPUS 1247 Jimmie Kerr Rd. • Graham, NC 27253
P.O. Box 8000 • Graham, NC 27253

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Dillingham Center

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Alamance Community College makes every effort to provide information on this Web site that is current and accurate. The ACC Web site and all materials maintained on the site are provided "as is" without warranties of any kind. Information on ACC's Web site is subject to change at the discretion of the College. In addition, ACC's Web site includes external links to Internet sites, content, and services provided by third parties. The College is not responsible for any errors in the materials provided on the Web Links accessible from ACC's Web pages. The College maintains the right to delete or add external links to third parties at its discretion and without notice.

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Public Safety

Employee Injury Form (Employee’s Form)

Employee Injury/Accident Statement Form

Instructions for Employees

Complete the “ACCIDENT/INCIDENT Employee Statement” form (SGWCP-2) below and submit within 48 hours of incident.

Employees are to go to a Fast Med Urgent Care location and present this form:

Download the Required Form here (PDF)

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.