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Injury Report Forms






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  4. Mekka






Injury Report Template

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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?

__________________________________________________________

__________________________________________________________

__________________________________________________________









Business Network Members
  1. Integrity Janitorial Serivce
  2. Just Foam
  3. Hobart
  4. M & T Dazzling Dustbusters






Continuous Improvement

Corrective Action
Workflow Chart
Job Safety Analysis
Risk Analysis Form
Employee Time Study Flow Sheet
Process Improvement Plan
Root Cause Failure Analysis Form

Reporting Accidents
Employee Incident Report
Employee Accident Report
Accident Claim Letter
Accident Claim Worksheet
Injury Report Form
Employee Accident Log
Fire Drill Report



End Of Employment
Employee Termination
Two Week Notice Letter
Resignation Letter
Farewell Letter For Retirement
COBRA Notification
Employment Verification

Exit Interview
Employee Exit Interview
Exit Interview Questions






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