Alabama Employee Injury Accident Report Form

To submit the Employee Injury Accident Report Form, complete it fully and provide it directly to your immediate supervisor on the day of the incident. You can submit it via email to SEICTF@finance.alabama.gov or fax to either 334-223-6170 or 888-827-6753. Make sure to keep a copy for your records and follow up with your supervisor to ensure it has been received.

The Alabama Employee Injury Report should be filled out immediately following an incident. Submissions are necessary within 48 hours to ensure timely processing of injury claims. Make sure to keep track of any deadlines established by your workplace for further claims or reporting procedures.

The purpose of the Employee Injury Accident Report Form is to provide a structured and thorough account of workplace injuries. This report is vital for ensuring employees receive the necessary support and compensation through the State Employee Injury Compensation Trust Fund (SEICTF). By accurately completing this form, employees aid supervisors and HR in processing their claims efficiently, ensuring compliance with workplace regulations.

• 1. Time of Injury/Accident: Indicates the exact time when the incident occurred.
• 2. Date of Injury/Accident: Records the date on which the injury took place.
• 3. Employee Name: To be filled with the full name of the injured employee.
• 4. Date of Birth: Captures employee's date of birth for identity verification.
• 5. Social Security Number: Requires the complete SSN for employee identification.
• 6. Street Address: To be filled with the employee's residential address.
• 7. City: Indicates the city of the employee's residence.
• 8. State: Captures the state of residence.
• 9. Zip Code: Records the postal code of the employee's address.
• 10. Primary Phone Number: For any immediate contact related to the incident.
• 11. Email Address: To provide a means for electronic communication.
• 12. Preferred Method of Contact: Employee's choice of receiving correspondence.
• 13. Job Title/Class Code: Identifies the employee's position within the organization.
• 14. Name of Supervisor: The supervisor who is informed of the incident.
• 15. Date Supervisor Notified: Date when the supervisor was made aware of the injury.
• 16. Describing the Accident: Detailed description of the events leading to the injury.
• 17. Injuries/Body Part(s): Specific injuries sustained by the employee.
• 18. Location of Injury: Exact site where the injury occurred.
• 19. Witness Information: Contact details of any witnesses.
• 20. Protective Equipment Used: Details of safety gear utilized at the time of the injury.
• 21. Prior Injuries: Records if the employee has previously hurt the same body part.
• 22. Signature of Employee: The employee's signature certifying the information is correct.
• 23. Date: The date when the form is signed.
• 24. Signature of Supervisor: Supervisor's signature on the report.
• 25. Date: Date when the supervising signature is applied.

Failure to submit this form can result in delays in your injury claim processing and may hinder your access to necessary compensation. It is crucial to adhere to the submission timelines outlined by your employer. Additionally, neglecting to submit this form can result in disciplinary action from your employer.

• Delay in Compensation: Not submitting the form may extend the time it takes to receive benefits.
• Ineligibility for Benefits: Failure to file may disqualify you from receiving entitled support.
• Impact on Employment Records: Incomplete reporting may affect your employment record.
• Increased Scrutiny: Employers may scrutinize claims more closely in absence of proper documentation.
• Potential for Legal Issues: Lack of form submission can lead to disputes or legal challenges.

• 1. Workplace Injuries: To document incidents that occur while performing job duties.
• 2. Filing for Worker’s Compensation: Necessary for employees seeking compensation for work injuries.
• 3. Incident Reporting: To maintain accurate records of workplace incidents.
• 4. Compliance with Policies: Ensures adherence to employer safety protocols.
• 5. Legal Documentation: Used in any legal claims that may arise from the injury.