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