Employee Injury Incident Report

Employee Injury Incident Report

This form is to be filled out by department supervisors when an incident or injury occurs with a staff member in their department. The form requires the filler to provide details about the incident/injury, including when/where it happened, what occurred, and any immediate and follow-up actions taken.
Employee Involved in Incident
Employee Name

First NameLast Name
Employee Position
Employee Email
example@example.com
Department Supervisor Information
Name of Supervisor of Employee (filling form out)

First NameLast Name
Email of Supervisor of Employee
example: dept manager
Was the supervisor a witness to the incident?
Incident Details
Date and Approximate Time of Incident

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Location of Incident
Type of Incident

Other
Please describe exactly what happened:
Please include details of: environment, weather conditions, other people involved, etc.
If this incident involved a bodily injury, please specify exactly where on the body this injury occured:
EX: top of head, right side temple, right leg below the knee, etc.
What was the employee doing immediately before the incident occurred? Please provide as many details as possible (stock #, work order #, vehicle being worked on, etc.)
What happened immediately after the incident?
Example: stopped work, notified manager, received first aid, continued working, equipment was shut down, left work, or sought medical attention.
Was there any equipment, machinery, tools, vehicles, or other property involved?
If yes, identify the equipment/vehicle/property involved, including stock number, VIN, licence plate, or other identifier where applicable.
Injury/Medical Attention
Was anyone injured?
If yes, who?
Describe the injury and parts of the body affected?
Was first aid provided?
If yes, who provided it and what type of first aid was provided?
Was outside medical attention sought out?
Did the employee leave work immediately after the incident?
Witnesses/Evidence
Were there any witnesses?
List the names of all witnesses
Camera Footage
Is there security camera footage that captured the incident?
If this incident is on camera, please list the camera view below
leave blank if none
And the time stamp on that camera of when this happened:
leave blank if none
Were any photos or videos of the incident taken?
Please upload photos/documents of the incident here:

Photos of the setting, area where injury occured, clips from the camera footage, etc.
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Upload photos of the injuries (if visible) here:

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Reporting and Management
Who was the incident first reported to?
Date and Time of Initial Report

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
How was it reported?

Other
What action was taken immediately following the incident?
Supervisor Comments/Notes
Acknowledgement & Accuracy of Reporting

Review the information documented in this report carefully before signing. Your signature confirms that the information recorded accurately reflects the details you provided regarding the incident, to the best of your knowledge.
Employee Acknowledgement

Employee Involved in Incident
Employee Acknowledgement: I confirm that I have reviewed the information recorded in this Incident Report and that, to the best of my knowledge, it accurately reflects the information I provided regarding this incident. I understand that this report documents the circumstances as currently known and may be used by the company for investigation, workplace health and safety, insurance, WSIB, or other applicable reporting purposes.
Employee Name

First NameLast Name
Manager Acknowledgement

Supervisor writing up form
Manager/Supervisor Acknowledgement: I confirm that I completed this report based on the information provided by the employee and any information available to me at the time of reporting. The completion of this report does not constitute a determination of cause, responsibility, or eligibility for any claim or benefit.
Manager/Supervisor Name

First NameLast Name
Should be Empty:

Employee Injury Incident Report

Employee Involved in Incident

Department Supervisor Information

Incident Details

Injury/Medical Attention

Witnesses/Evidence

Camera Footage

Reporting and Management

Acknowledgement & Accuracy of Reporting

Employee Acknowledgement

Manager Acknowledgement