Employer’s Accident Report (EAR) must be completed by the employee’s supervisor or co-worker within 3 days of injury. Then, email or fax report to Human Resources (E-mail is preferred; Fax: 434/977-7749). After emailing or faxing form, mail original signed EAR to Human Resources.
SECTION 1 – Injured Employee Information
Injured Employee Name:	Time Work Began:
Home Address:
City:	State:	Zip:
Office Phone:	VDOF Cell Phone:
Date of Birth:
Marital Status:	Single	Married	Divorced	Widowed
Job Title:	Date of Hire:
SECTION 2 – Injury Information
Date and Time of Injury/Illness:	Date:	Time:
Zip Code, County or City Where Injury/Illness Occurred:
Date Injury Was Reported:	Reported to Whom:
Name(s) of Witness(es):
List Machine, Tool or Object Causing Injury/Illness:
Describe Fully How Injury/Illness Occurred (Use as much space as necessary):
Describe Nature of Injury/Illness, Including Parts of Body Affected (Use as much space as necessary):
SECTION 3 – Medical Treatment
Did Injured Seek Medical Attention from a Preferred Panel Physician?	No	Yes (provide the following)
Doctor Name:
Doctor Address:
Doctor Phone:
Was Injured Treated at an Emergency Room?	No	Yes (provide the following)
Hospital/Clinic Name:
Doctor Name:
Hospital/Clinic Address:
Has Injured Returned to Work?	No	Probable Length of Disability:
Yes	Date of Return to Work:
SECTION 4 – Employee Reporting Accident (person completing this form)
VDOF Employee Completing this Form Name (Print)	VDOF Employee Completing this Form Signature	Date
If a doctor was seen, don’t forget to include the Form 8.30 Panel Physicians Form. If a prescription was written, print the Form 8.31 Prescription First Script Form for the Pharmacy.