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OTHER NAMES Work Injury Report Form

What is a Work Injury Report?

One of your employees was just injured on the job, but don't panic. A Work Injury Report can help you properly record what happened. It's a simple interview form. Plus, it can help you quickly fill out additional injury reports. The Work Injury Report is what you hope to never need - but it can make tough situations a little easier.

People quickly forget the details, but a Work Injury Report can help get the facts. Sometimes accidents aren't really accidental. Sometimes somebody was negligent. It doesn't really matter - at least right now - who's at fault. What matters is getting the facts written down. You don't want to stress out the person who's injured. They might be shaken up and not clearly remember what happened. The best way to get the truth is by asking the right questions as soon as possible. Make sure statements are written down. But how do you know the right questions to ask? Our Work Injury Report can help you make sure you've covered everything.

When to use a Work Injury Report:

You were recently injured on the job.
An employee was recently injured on the job.

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WORKPLACE INJURY AND INCIDENT REPORT

Company:

Company Name:

Company Representative's Name:

Company Representative's Title:

Company Name:


Company Address:

, ,

Employee:

Employee's Name:

Company Name:


Employee's Address:

, ,

Date of Birth:

Date of Hire:

Incident Details:

Incident Case Number:

Date of Incident:

Time of Incident: Time cannot be determined

Employee's Workday Start Time:

Incident Investigation Date and Time:

Events Leading Up To the Incident:

Details of the Incident:

The Results of the Incident:

Objects or Substances involved in the incident:

Medical Treatment Required: was did


Report Completed By:	_________________________________________