Employee Injury Report

EMPLOYEE INJURY REPORT

Instructions: Employees shall use this form to report all work related injuries, illnesses, or “near miss” events (which could have caused an injury or illness) – no matter how minor. This helps us to identify and correct hazards before they cause serious injuries. This form shall be completed by employees as soon as possible and given to a supervisor for further action.
Property:*
Select the property the incident took place
I am reporting a work related:*

InjuryIllnessNear Miss
Your Name:*

First NameLast Name
Job Title:*
Supervisors Name:*
Have you told your supervisor about this injury/near miss?*

YesNo
Date and Time of injury/near miss:*

DayMonthYear
Date
Hour MinutesAM/PM Option
Names of witnesses (if any):
Where, exactly, did it happen?*
Describe step by step what led up to the injury/near miss:*
What could have been done to prevent this injury/near miss?*
What parts of your body were injured? If a near miss, how could you have been hurt?*
Did you see a doctor about this injury/illness?*

YesNo
If yes, whom did you see:
Doctors Phone Number:
Please enter a valid phone number.
Date and Time of Doctors Appointment:

DayMonthYear
Date
Hour MinutesAM/PM Option
Has this part of your body been injured before?*

YesNo
If yes, when?
General Managers Name:*
General Managers Email:*
A copy of this report will be sent to this managers email upon clicking Submit. PLEASE NOTE: If you are unsure please select chris@saltwaterproperties.com
Signature of person completing report:*

Clear
Please verify that you are human:*
Should be Empty:

EMPLOYEE INJURY REPORT