Injury report form

Health & Medicine

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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