Employee'S Report Of Injury Form printable pdf download

Employee'S Report Of Injury Form

Employee’s Report of Injury Form

Instructions: Employees shall use this form to report all work related injuries, illnesses, or

“near miss” events (which could have caused an injury or illness) – no matter how minor. This

helps us to identify and correct hazards before they cause serious injuries. This form shall be

completed by employees as soon as possible and given to a supervisor for further action.

I am reporting a work related:

Injury

Illness

Near miss

Your Name:

Job title:

Supervisor:

Have you told your supervisor about this injury/near miss?

Yes

Date of injury/near miss:

Time of injury/near miss:

Names of witnesses (if any):

Where, exactly, did it happen?

What were you doing at the time?

Describe step by step what led up to the injury/near miss. (continue on the back if necessary):

What could have been done to prevent this injury/near miss?

What parts of your body were injured? If a near miss, how could you have been hurt?

Did you see a doctor about this injury/illness?

Yes

If yes, whom did you see?

Doctor’s phone number:

Date:

Time:

Has this part of your body been injured before?

Yes

If yes, when?

Supervisor:

Your signature:

Date:

Employee'S Report Of Injury Form