INCIDENT/ ACCIDENT REPORT FORM

Incident or Accident Report/ Reporte de Incidente o Accidente

Please fill out this form to notify us of any work related incidents or accidents./ Por favor, complete este formulario para notificarnos cualquier incidente o accidente relacionado con el trabajo.

First name/ Primer Nombre

Last name/ Apellido

Email address/ Correo electronico

Phone number/ Numero de telefono

Professional title/ Titulo del empleado

Customer and Supervisor Name/ Cliente y Nombre del supervisor

Where did the incident or accident happen?/ Donde occurio el incidente o accidente?

Do you require medical assistance?/ Necesitas asistencia medica?

When did the incident or accident happen?/ Cuando ocurrio el incidente o accidente?

Month

Day

Year

Time

HoursMinutes

Describe what happened/ Describa lo ocurrido

Are you still employed with JPA Workforce?/ Aun esta empleado con JPA?

Signature/ Firma

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