Work Injury Report

Name of person involved*

First Name

Last Name

Employee Home Address

Address Line 1

Address Line 2

City

State

ZIP Code

Home Phone

Date and Time of Injury

Location of Incident

Describe how the incident occurred

Explain the operation in which you were involved. What were you doing before the incident occurred? What was your goal? What were you doing at the time the incident occurred? What were the conditions of your work? Is this a routine operation?

Describe the incident in detail. What happened?

Describe the sequence of events that led up to the incident.

Did you sustain any injuries? What were they? How were they treated? Did you require medical care? Describe the severity of the injury.

Was First Aid Administered?*

Yes No

Was the employee treated off site?*

Yes No

Causal Factors

What are your recommendations for preventing recurrence?

Date

Employee Signature

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To Be Completed By Supervisor

Person Incident Reported to?

If employee was treated, what was the location?

Signature

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