Employee Injury Report Form
Todays Date
-
Month
-
Day
Year
Date Picker Icon
Employee Name
*
First Name
Last Name
Employee's Manager's Name
*
First Name
Last Name
Incident Date and Time
*
-
Month
-
Day
Year
Date Picker Icon
Location
*
Description of Incident
*
What were you doing at the time? Describe step by step what led to the injury.
Employee Explanation/Notes
*
What parts of your body were injured? I
Witness/Witnesses
*
Signature
*
Clear
Submit
Should be Empty: