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:
Your Name
Job title
Supervisor
Date of injury/near miss

MonthDayYear
Time of injury/near miss
Have you told your supervisor about this injury/near miss? Date of injury/near miss:
Describe what led up to the injury/near miss
Where exactly did it happen
What were you doing at the time
What could have been done to prevent this injury/near miss
Names of witnesses, if any
Did you see a doctor about this injury/near miss? If yes, whom did you see?
Date seen by Doctor (leave blank if not seen)

MonthDayYear
Doctors phone number
Has this part of your body been injured before?
If yes, when?
Upload images of injured area

Cancelof
Your signature

Clear
Date

MonthDayYear
Date
Supervisor's Accident Investigation Form
Name of Injured Person
Date of Birth

MonthDayYear
Date
Telephone Number
Gender

MaleFemale
What part of the body was injured? Describe in detail.
What was the nature of the injury? Describe in detail.
Describe fully how the accident happened, include what was the employee doing prior to the event and what equipment/tools were being using
Names of all witnesses
Date of Event

MonthDayYear
Date
Exact location of event
Were safety regulations in place and used? If not, what was wrong?
Did employee go to doctor/hospital? Doctor's Name
Doctors Name, if applicable
Hospital Name, if applicable
Recommended preventive action to take in the future to prevent reoccurrence
Date of Incident

MonthDayYear
Date
Time of Incident

Hour Minutes

AM/PM Option
Supervisor Signature

Clear
Describe how the injury occurred.
Nature of Injury (if multiple, select the most serious)
This employee works:
Months with this employer
Months doing this job
Exact location of the incident
What personal protective equipment was being used if any
Were there any unsafe employee actions? (select all that apply)
Were there any unsafe workplace conditions? (select all that apply)
Why did the unsafe conditions exist
Why did the unsafe acts occur
If yes describe
What should be or has been done to carry out the suggestions checked above
Who completed and reviewed this form?
Title
Names of investigation team members
Reviewed by
Date

MonthDayYear
Date
Title
Should be Empty: