Colorado Recreation Company

28368 Constellation Road #480 Valencia, CA 91355

(805) 285-3229 Fax: (661) 845-2046

FORM – AR23

ACCIDENT REPORT

Location:________________________________ Date of Accident:______________________

Time of Accident:______________________

Age / Date of Birth:_____________________________ Day/Time Reported:______________

Were pictures taken?: YES / NO

Medical Attention Given:_________________________________________________________

____________________________________________________________________________

Part of body injured:___________________________________________________________

Nature of Injury (Cut, bruise, burn, strain, etc.):_____________________________________

___________________________________________________________________________

Contributing Factors to Accident:_________________________________________________

Employee Signature Date

___________________________________________ _______________

Supervisor Signature Date