Official VOSHA Injury Report
All injury reports must be made within 72 hours of the incident.
Reported by
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First Name
Last Name
Position/ Role
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Email
*
Phone Number
*
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Area Code
Phone Number
Date of Injury
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Month
/
Day
Year
Date Picker Icon
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Hour
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10
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30
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50
Minutes
AM
PM
AM/PM Option
Location of Injury
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Location (Hotel, Rink, etc.)
Street Address
City
State / Province
Postal / Zip Code
Name of the Injured Party
*
First Name
Last Name
Secondary Party Involved (if applicable)
First Name
Last Name
Description- How did incident occur?
*
Description of injuries
*
Description of injuries
*
First Aid treatment given (if applicable)
Upload documents
Browse Files
Attach any applicable files pertaining to this report
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of
Name of Witness
First Name
Last Name
Secondary Witness Name
First Name
Last Name
Secondary Witness Name
First Name
Last Name
I certify
*
I hereby certify that all information entered above is valid and true.
Signature
*
Your signature acknowledges that you are submitting this form to the VOSHA Administrator and are aware of and acknowledge the contents of this document to be true.
Submit
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