1. 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:_______________________________________

2. __________________________________________________________________________
Prepared by (print)
__________________________________________________________________________
Signature
____________________________
Date