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ACCIDENTS
INTAKE FORM

BACKGROUND INFO

Address
Date of birth
Month
Day
Year
Time of the accident
Time
:
Working at the time?
Yes
No
If yes, making a comp claim?
Yes
No

Location of the accident

(i.e. workplace, construction site, store, public place)

Type of accident

TREATMENT

Ambulance?
Yes
No
Emergency room?
Yes
No

INJURIES

FOLLOW UP TREATMENT



to

Losing time from work?
Yes
No
Was there property damage?
Yes
No

Was property damage documented (photos/videos)?


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