Title Page

  • Employee name

  • Conducted on

  • Location

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:

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.