Employee’s Report of Injury Form

Employee’s Report of Injury Form
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.
I am reporting a work related:

InjuryIllnessNear Miss
Full Name*

First NameLast Name
Job Title
Supervisor*

First NameLast Name
Have you told your supervisor about this injury/near miss?

YesNo
Date of injury/near miss:*

MonthDayYear
DateHourMinutesAM/PM Option
Names of witnesses (if any):
Where, exactly, did it happen?
What were you doing at the time?
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?

First NameLast Name
Doctor’s phone number:

Area CodePhone Number
Date

MonthDayYear
DateHourMinutesAM/PM Option
Has this part of your body been injured before?

YesNo
If yes, when?

MonthDayYear
Date
If yes, whom did you see?

First NameLast Name
Doctor’s phone number:

Area CodePhone Number
Date*

MonthDayYear
Date
Signature*

Clear

p. 443.979.7171

AAA Physical Therapy, LLC
admin@AAAPhysicalTherapy.com
8975 Guilford Rd Ste 170 Columbia, MD 21046

f. 667.200.5908