Injury Details
Date and time of event

To whom did you report the injury?

What was the date and time it was reported?
Exact location of event

What part of the body was injured? Describe in detail

Take photo of the body part that was injured. Annotate as required

What was the nature of the injury? Describe in detail

Describe fully how the incident happened?

What were you doing prior to the event?

Take photo of the surrounding environment where you were working prior to the event

Was equipment, tools being used?

Explain what equipment, tools were being used?

Take a picture of the tool.

What caused the event?

What other factors contributed to the injury (weather, lighting, accessibility, condition of property, etc.)?

Were safety regulations in place and used?

What was wrong?

Recommended preventive action to take in the future to prevent reoccurence

Witness Statements

Were there any witnesses?

Add witness


Enter witness name

Contact number

Emergency Services

Employee went to doctor/ clinic?

Doctor's Name

Clinic's Name

Clinic Phone Number

Police were called to the scene

Name of the Agency Reported to?

Police reference number

Take a photo of any documents given by the police officer
Customer Information

Customer's Name

Work Order Number

Customer's Phone Number

Sign off
Injured person signature
Supervisor signature

This document when complete should be sent by email to: and your FSM.

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.