This injury report form collects information about a workplace incident involving an employee. It records the employee's name, job title, department, date and time of incident, location, and who the incident was reported to. It also describes the incident and any resulting injury. Additional details include whether the incident was recorded on an OSHA form, where treatment was given, the type of treatment, and whether the employee can return to work and if so, when. The form is signed and dated by the person who prepared it.

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