Work Injury Report

Describe how the incident occurred

Explain the operation in which you were involved. What were you doing before the incident occurred? What was your goal? What were you doing at the time the incident occurred? What were the conditions of your work? Is this a routine operation?
Describe the incident in detail. What happened?
Describe the sequence of events that led up to the incident.
Did you sustain any injuries? What were they? How were they treated? Did you require medical care? Describe the severity of the injury
Was First Aid Administered?*

YesNo
Was the employee treated off site?*

YesNo