EMPLOYEE REPORT OF INJURY/INCIDENT
(To be completed by the employee only)
Employee Information
Employee's Name
*
Gender
*
Male
Female
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Phone Number
*
Format: (000) 000-0000.
Address
*
Job Title
*
How Long Employed Here
*
Incident Information
Location of Incident
*
Date of Incident
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Time of Incident
*
AM
PM
AM/PM Option
Describe full how the incident occurred
*
Include events that occurred immediately before the incident
Describe bodily injury sustained
*
Be specific about body part(s) affected
Describe the root cause of the incident
*
Recommendation on how to prevent this incident from recurring
*
Supervisor/Witness Information
Name of Supervisor
*
Supervisor Phone Number
*
Format: (000) 000-0000.
Were there any witnesses
*
Yes
No
Configurable list
*
Date when reported to Supervisor
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Time reported to Supervisor
*
AM
PM
AM/PM Option
Who did you report the injury
*
First Name
Last Name
Do you require medical attention?
*
Yes
No
Maybe
Name of Your Treating Physician
Physician Phone Number
Format: (000) 000-0000.
*
By checking this box, you affirm that the information provided above is true, complete, and accurate to the best of your knowledge.
Signature
*
Submit
Should be Empty: