Injury Investigation Report
CS Construction, Inc.
Employee Name
*
First & Last Name
Type of Incident
*
Accident
Injury
Chemical Spill
Fire
Near Hit
Off-Site Motor Vehicle Addicent
Power Loss
Other
Date & Time of Incident
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
On Overtime?
*
Yes
No
Date & Time Incident Reported
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Job Number
*
Ex: 1766A
Supervisor Name
*
First & Last Name
Other Employees Involved?
*
Yes
No
Other Non-Employees Involved?
*
Yes
No
Witnesses?
(If Any)
Tasks Being Done Just Prior To Incident Occurring?
*
Describe The Incident
*
Please Share Details
List Equipment, Tools, Materials Being Used
*
Include Any Other Items Involved
Indicate The Type of Incident
*
Fall (Two Levels)
Fall (Same Level)
Caught In/Under/Between
Overexertion
Struck By
Struck Against
Hazardous Contact
Other
Was There An Injury?
*
Yes
No
Type of Injury
*
Amputation
Bruise
Chemical Reaction
Crush
Cut
Electric Shock
Foreign Body
Fracture
Irritation (Eyes)
Irritation (Nose/Throat)
Irritation (Skin)
Puncture
Sprain
Strain
Injuries (Employee & Others)
*
List All Injuries
Injured Part of Body (Most Serious)
*
Abdomen
Ankle (Left)
Ankle (Right)
Arm (Lower Left
Arm (Lower Right)
Arm (Upper Left)
Arm (Upper Right)
Back
Buttocks
Chest
Chin
Ear (Left)
Ear (Right)
Eye (Left)
Eye (Right)
Face
Finger
Foot (Left)
Foot (Right)
Forehead
Groin
Hand (Left)
Hand (Right)
Head
Hip (Left)
Hip (Right)
Knee (Left)
Knee (Right)
Leg (Lower Left)
Leg (Lower Right)
Leg (Upper Left)
Leg (Upper Right)
Mouth
Neck (Front)
Neck (Rear)
Nose
Shoulder (Left)
Shoulder (Right)
Thumb
Toe (Big)
Toe (Small)
Injury/Illness Treatment Provided
*
At Location
Taken To Hospital
None
Employee Written Statement
*
Reported Completed By Supervisor Name
*
First & Last Name
Submit
Should be Empty: