Injury Report Form

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Injury Report
Name:
Date:
Employee ID:
Title:
Sex:
DOB:
Email Address:
Phone:
Address:
Incident
Date of Accident:
Time of Accident:
Reported to:
Reported by:
How did the injury occur?
Witnesses:
Others Involved:
q Equipment Malfunction
q Safety Violation
q Collision
q Fall/Falling Object
Caused by:
Other:
Injury
Description of Injury:
q Burn q Cut q Bruise q Scrape q Break q Sprain q Strain q Concussion
Nature of Injury:
Other:
Part(s) of Body Affected
q Left q Right
q Foot
q Ankle
q Knee
q Shin
q Calf
q Thigh
q Buttocks
q Waist
q Hip
q Groin
q Stomach
q Ribs
q Chest
q Back
q Shoulder
q Neck
q Hand
q Wrist
q Forearm
q Elbow
q Bicep
q Head
q Forehead
q Ears
q Eyes
q Nose
q Mouth
q Chin
Care
Doctor:
Hospital:
Insurance:
Account No:
Care Provided:

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