Report of Employee Injury or Illness

Report of Employee Injury or Illness
Employee's Name*

First NameLast Name
Date of Injury *

MonthDayYear
DateHourMinutesAM/PM Option
Nature of Injury*
Part of Body Injured or Exposed*
How and Why Injury/Illness Occured*
When did the injury happen?

At WorkOutside of Work
Was employee doing his/her regular job?

YesNo
Worksite Location of Injury (Stairs, dock, etc)*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Cause of Injury (fall, tool, machine, etc)*
List of Witnesses
Injury Classification

Likely to be First Aid OnlyLikely to be a Recordable Injury
Return to work date/or expected

MonthDayYear
Date
Supervisor

Chris PettisCody ZimmermanEric O'DonelJoe Perez IIIJoey BuddJosh DiGulioKris GardnerPaul Schaider/Matt BunseyMichael KovalSean McCabeSean SesherZach McCoyOther
Date Reported

MonthDayYear
Date
Name of Person Completing Form

First NameLast Name
Signature

Clear
Date

MonthDayYear
Date
Should be Empty: