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Injury Report
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EMPLOYEE
EMPLOYEE NAME
Your answer
POSITION
Your answer
SOC. SEC. NO.
Your answer
DEPARTMENT
Your answer
EMPLOYEE ID NO.
Your answer
SUPERVISOR
Your answer
INJURY INFORMATION
DATE OF OCCURRENCE
MM
/
DD
/
YYYY
TIME
Time
:
AM
PM
LOCATION
Your answer
DESCRIBE ACTIVITY PRIOR TO INJURY
Your answer
WHAT HAPPENED (DESCRIBE CAUSE AND OBJECT OF INJURY)
Your answer
I CERTIFY BY MY SIGNATURE THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND COMPLETE.
EMPLOYEE SIGNATURE
Your answer
DATE
MM
/
DD
/
YYYY
SUPERVISOR SECTION
WHEN DID YOU FIRST LEARN OF THE INJURY?
Your answer
BASED ON YOUR INVESTIGATION, WHAT WAS THE CAUSE OF THE INJURY?
Your answer
HOW COULD THIS INJURY HAVE BEEN PREVENTED?
Your answer
WHAT ACTIONS HAVE BEEN TAKE TO AVOID FUTURE INJURIES OF THIS TYPE?
Your answer
WITNESSES: (NAME)
Your answer
WITNESSES: (ADDRESS)
Your answer
WITNESSES: (PHONE)
Your answer
SUPERVISOR SIGNATURE
Your answer
DATE
MM
/
DD
/
YYYY
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