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Employee's Name Date of Birth Gender Job Position/Title Driver License # State Issued Supervisor's Name Shift Hours Days Off Date/Time of Accident Location of Accident Date/Time Accident was reported To whom? Task being performed when accident occurred Were you using your cell phone at the time of the accident? Was your computer on at the time of the accident? Name of Witness Address Phone Name of Witness Address Phone Describe in detail how the accident occurred Describe the injuries or damages in detail Could anything be done to prevent accidents of this type? Y / N If so, what? Signature of Employee Date OGDEN CITY EMPLOYEE'S REPORT OF ACCIDENT All Ogden City employees involved in an accident involving injury or property damage are to compete the Employee's Report of Accident form. In all accidents, employees are required to immediately inform a supervisor and complete this form on the same day of the accident. Copy 1 - Risk Management Copy 2 - Department Copy 3 - Employee Copy 4 - Fleet