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Injury Report Form

This injury report form documents an incident involving an employee of [Company Name]. It records the employee's name, job title, department, date and time of the incident, location, who it was reported to, and a description of what happened. The form also documents the employee's resulting injury, whether it was recorded on an OSHA form, where treatment was given, the type of treatment, and whether the employee can return to work and if so, when, or how many days off are required if not. The form is prepared and signed by the person documenting the incident.

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HOSAM HUSSEIN
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© Attribution Non-Commercial (BY-NC)
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306 views2 pages

Injury Report Form

This injury report form documents an incident involving an employee of [Company Name]. It records the employee's name, job title, department, date and time of the incident, location, who it was reported to, and a description of what happened. The form also documents the employee's resulting injury, whether it was recorded on an OSHA form, where treatment was given, the type of treatment, and whether the employee can return to work and if so, when, or how many days off are required if not. The form is prepared and signed by the person documenting the incident.

Uploaded by

HOSAM HUSSEIN
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Injury Report Form

[Company Name]

Employee Name:_______________________________________________________
Job Title:______________________________________________________________
Department:___________________________________________________________

Date/Time of Incident:_________________________________
Location:___________________________________________________________
Date/Time reported:____________________________________
Reported to:_____________________________________________________________
Description of incident:___________________________________________________
________________________________________________________________________
________________________________________________________________________
Description of injury:
________________________________________________________________________
________________________________________________________________________

Recorded on OSHA Form?


Where was treatment given?_______________________________________________
What type of treatment was given?__________________________________________
Is employee able to return to work?_________________________________________
If yes, when?_____________________________________________________________
If no, how many days off are required:_______________________________________

__________________________________________________________________________
Prepared by (print)

__________________________________________________________________________
Signature

____________________________

Date

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