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Employee Statement

How I got hurt?

Employee Name

Occupation

Address

Phone number

Date of birth
Date and Time of Incident
If not incident, date of onset of illness
Where did the incident happen?

Is someone notified of the injury?

Who was notified?

Date and Time notified

What happened and how did it happen?

If you feel any of the symptoms, list the areas of the body where you feel them and indicate which type of symptom. (click "Add Body Part")

Body Part

Specify body part

Symptom types
Scale of pain
Take / upload a photo of the body part

Provide details

Was the employee the one who fill out this form?

Do you want medical treatment right now?

Authorization for Release of Medical Information:
I hereby authorize any and all providers of medical or surgical treatment deemed necessary in regard to my reported occupational injury or illness to release any medical information acquired in the course of my treatment

Employee's Signature
Name and Signature of Preparer

As told to me by (Name of Injured Employee)

Reason why injured worker could not complete this form:

Employee Incident Report Checklist

Created by: SafetyCulture Staff | Industry: General | Downloads: 187

Employees can use this form to report all work related injuries, illnesses or near miss events no matter how minor. This template should be completed by employees and reviewed by a supervisor as soon possible after an incident occurs.

Signup for a free iAuditor account to download and edit this checklist. It will be added to your free account and you will be able to conduct inspections from your mobile device.

Download and edit this free checklist

Browse for other checklists


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Audit

Employee Statement

How I got hurt?

Employee Name

Occupation

Address

Phone number

Date of birth
Date and Time of Incident
If not incident, date of onset of illness
Where did the incident happen?

Is someone notified of the injury?

Who was notified?

Date and Time notified

What happened and how did it happen?

If you feel any of the symptoms, list the areas of the body where you feel them and indicate which type of symptom. (click "Add Body Part")

Body Part

Specify body part

Symptom types
Scale of pain
Take / upload a photo of the body part

Provide details

Was the employee the one who fill out this form?

Do you want medical treatment right now?

Authorization for Release of Medical Information:
I hereby authorize any and all providers of medical or surgical treatment deemed necessary in regard to my reported occupational injury or illness to release any medical information acquired in the course of my treatment

Employee's Signature
Name and Signature of Preparer

As told to me by (Name of Injured Employee)

Reason why injured worker could not complete this form: