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Click ‘Get Form’ to open the DOE Form 5484.3 in the editor.
Begin by filling out the 'Organization Name' and 'Organization Code' fields at the top of the form. Ensure accuracy as this information is crucial for identification.
Proceed to enter the 'Case Number' and 'Date of Occurrence'. Use the provided format for dates to avoid errors.
In the 'Accident Type' section, select the appropriate options based on the incident details. This helps categorize the report correctly.
Complete sections related to employee information, including name, age, and occupation. Be sure to check one of the options under 'Check One' for clarity.
For injury/illness details, accurately fill in workdays lost and restricted fields if applicable. This data is essential for compliance.
Finally, provide a detailed narrative in the designated section without including personal identifiers. This should describe events leading up to and following the accident.

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