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). 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

Choose one

Injury

Illness

Near Miss

Name

First Name

Last Name

Names of witnesses (if any):

Job Title

Supervisor(s)

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

Yes

Date of injury/near Miss

YYYY

Did you see a doctor about this injury/illness?

Yes

If yes, whom did you see?

Doctor's Name & Phone Number

Date seen by doctor if answer is yes

YYYY

Time when seen by doctor if answer is yes

Where, exactly, did it happen?

What were you doing at the time?

Describe step by step what led up to the injury/near miss.

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?

Has this part of your body been injured before?

Yes

If yes, when?

YYYY

Signature

Today's Date

YYYY

Location

Contact

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