Accident/Incident Reporting Form Accident/Incident Reporting Submit this form to notify the Noodle Team of ANY and EVERY accident that happens on EMC premises - both guest and employee accidents. Manager:* First Last Date of Accident:* MM slash DD slash YYYY Location of Accident:*Select OneBentonConwayBreckenridgeNorth Little RockSiloam SpringsRiverdaleIs the injured an employee or guest?*GuestEmployeeName of Injured Employee:* First Last Injured Employee Phone #:*Is the injured employee under the age of 18?*YesNoDescription of what happened, including the condition of the area before the accident occurred and the behavior of the injured employee that led to the accident:*Did the Employee receive care instructions and care product from the first aid kit?*YesNoDid the employee sign the Burn/Cut Waiver?*YesNoDid the accident require medical assistance (hospital, urgent care, doctor visit)?*YesNoIf medical assistance was needed, did you fill out Form AR-N?*YesNoUpload Image of Accident Report*Max. file size: 200 MB. CAPTCHA Δ
