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Injury Report Forms







Injury Report Template



Injury Report Form


Employee Information:

Full Name: _______________________

Address: _________________________

City: __________ State: ___ Zip: ____

Date of Birth: ____/____/______

Hired Date: ____/____/______

[__] Male [__] Female

Physician Information:

Physician Name:

________________________________

Where was treatment for the injury provided?

Facility:

________________________________

Address: _________________________

City: __________ State: ___ Zip: ____

Was the employee treated at a hospital emergency room?

[__] Yes [__] No

Did the employee stay overnight at the hospital as an in-patient?

[__] Yes [__] No

Case Incident Information:

Case number from the log: #____

The date of the injury or illness:

____/____/______

The time the employee started work the day of the incident:

____:____ AM / PM

The time of the incident:

____:____ AM / PM

[__] Check if no approximate time is available.

Just before the incident occurred, what was the employee doing?

________________________________

________________________________

________________________________

How did the injury occur?

________________________________

________________________________

________________________________

What was the specific injury or illness that was a result of the incident?

________________________________

________________________________

________________________________





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