Incident / Injury Report
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Please PRINT or TYPE
Date/Time of Incident
Location: Street, City, Building, Room No. (Be specific)
TIME
& PLACE
Type of Premises
Conditions
Police Report
Which Agency:
Construction Site
Parking Lot
Dry
Uneven Surface
Hallway
Sidewalk
Icy
Other:
PREMISES
Lobby/Entrance
Stairway
Snowy
Report #
CONDITION
Office
Street
Wet
Other:
Not Reported
Describe What Happened (Use additional sheet if necessary):
INCIDENT
DESCRIPTION
Name
Age
Phone No.
INJURED
PERSON
Address
Social Security Number:
Injury - Describe the type, severity, and body part involved
DESCRIPTION
OF INJURY
Was Medical Treatment Given?
Yes
No
Will seek treatment later
&
MEDICAL
Name of Medical Facility/Doctor
Transported by Ambulance
TREATMENT
Transported by Other:
Owner’s Name
Address
Phone #
PROPERTY
Describe the property and the damage:
DAMAGE
Name
Address
Phone #
WITNESSES
Give the Full Name
and Address of
Each
Witness
Name/Title of the Employee
completing this Report
Phone #:
System Member:
Department:
Date:
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Parent category: Business