"Accident Reporting Form" - North Carolina

Accident Reporting Form is a legal document that was released by the North Carolina Department of Labor - a government authority operating within North Carolina.

Form Details:

  • Released on January 1, 2015;
  • The latest edition currently provided by the North Carolina Department of Labor;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the North Carolina Department of Labor.

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Accident Reporting Form
(Effective January 1, 2015)
N.C. Department of Labor
Cherie Berry
Commissioner of Labor
Employer Name:
Site Address:
Mailing Address:
Event Address
(If different):
Number of Employees
SIC Code:
NAICS Code:
at Establishment:
Type of Business: (if construction,
indicate commercial / residential)
Reported By:
Job Title:
Telephone Number:
Date and Time
Date and Time
Reported:
of Accident:
Event Description/Type of Injury:
Number of Injuries:
Number Hospitalized:
Number Still Missing:
Name of Victim:
Gender:
Race:
Age:
Date of Birth:
Type of Event:
o
o
o
In-patient Hospitalization
Amputation
Loss of an Eye
Next of Kin Name:
Next of Kin Address:
Next of Kin Relationship:
Name of Victim:
Gender:
Race:
Age:
Date of Birth:
Type of Event:
o
o
o
In-patient Hospitalization
Amputation
Loss of an Eye
Next of Kin Name:
Next of Kin Address:
Next of Kin Relationship:
Person in Charge at the Scene:
Suggestion: Save this as a document for your records and send as an email attachment
or
use the “Submit Form” button.
Submit Form
Reset Form
Accident Reporting Form
(Effective January 1, 2015)
N.C. Department of Labor
Cherie Berry
Commissioner of Labor
Employer Name:
Site Address:
Mailing Address:
Event Address
(If different):
Number of Employees
SIC Code:
NAICS Code:
at Establishment:
Type of Business: (if construction,
indicate commercial / residential)
Reported By:
Job Title:
Telephone Number:
Date and Time
Date and Time
Reported:
of Accident:
Event Description/Type of Injury:
Number of Injuries:
Number Hospitalized:
Number Still Missing:
Name of Victim:
Gender:
Race:
Age:
Date of Birth:
Type of Event:
o
o
o
In-patient Hospitalization
Amputation
Loss of an Eye
Next of Kin Name:
Next of Kin Address:
Next of Kin Relationship:
Name of Victim:
Gender:
Race:
Age:
Date of Birth:
Type of Event:
o
o
o
In-patient Hospitalization
Amputation
Loss of an Eye
Next of Kin Name:
Next of Kin Address:
Next of Kin Relationship:
Person in Charge at the Scene:
Suggestion: Save this as a document for your records and send as an email attachment
or
use the “Submit Form” button.
Submit Form
Reset Form