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:
Your Name:

First NameLast Name
Job Title:
Supervisors Name:
Have you told your supervisor about this injury/near miss?
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?
If yes, whom did you see:
Doctors Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Date and Time of Doctors Appointment:

DayMonthYear
Date
Hour MinutesAM/PM Option
Has this part of your body been injured before?
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:
Please verify that you are human:
Should be Empty:

EMPLOYEE INJURY REPORT