Employee Injury Report Form
Employee Name
Form completed by
Date of Birth
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Report Date
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Report Time
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Reported To
Host Organisation
Job Location
Supervisors Name
First Name
Last Name
Supervisors Number
Exact Address of Incident
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Injury Type
Near Miss- No one hurt
Minor Incident- 1st aid treated
Moderate Incident- Doctor treated
Serious Incident- Hospitalisation or Death
Other
Part of body affected (left arm, right leg etc)
Nature of injury (burn, sprain, cut etc)
Employee Explanation/Notes
Witness name and number if applicable
Attach any applicable documentations
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of
Attach any applicable documentations
Browse Files
Cancel
of
Submit
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