Injury Report

Please complete all sections. All fields are required unless specified as optional. If more space needed for any section, use the Other Notes field.

 

COMPANY INFORMATION
Company Name

 Company Phone Number

Address
City

 State 
 Zip
County

INJURED PERSON
Name

 Phone Number

Address
City

 State 
 Zip
County
 Date of Birth
Job Title
 Regular Working Hours
Start      Finish
Sex Soc. Sec. # (Last 4 digits)

 # of Dependants
Marital Status
 Spouses Name (if married)

INJURY INFORMATION
Location Name

 Location Phone Number

Address
City

 State 
 Zip
Date of Injury
 Time you began work
 Time of Injury
Vehicle/Power Unit involved?
 Unit Number (if yes)
Will injury cause
lost time from work?
 Will injury cause
work restrictions?
Wearing PPE?
 Describe PPE
List Witnesses (if any)
Witness 1
Witness 2
Witness 3
What were you doing before injury?
How did injury occur?
Describe Injury (Right/left side, back, arm, etc.)
What object/substance directly harmed you?
Did you receive
medical treatment?
 Where were you treated?
Were you treated
in the ER?
 Were you hospitalized?
Hospital / Clinic Name
 Phone Number
Address
City

 State 
 Zip
Additional Comments
Name of person filling out this form