Submit an Employee Accident Report

Please use the form below to submit accident reports for Town of Wakefield Employees. Please be sure to have your form ready for upload.

Employee First Name *

Employee Last Name *

Department: *

Date of Injury: *

Month

Day

Year

Any lost time? *

Yes

If yes, first date of absence.

Month

Day

Year

Has employee returned to work? *

Yes

If yes, return to work date.

Month

Day

Year

Upload Signed Accident Report *

Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png pdf.

Email of person completing this form: *

Leave this field blank

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