Employee Injury Report

• Prepared by:

Employee Information:

• Name of Injured Person:

• Employee Address:

• Contact Number:

• Date of Birth:

• Sex:

  Male

  Female

• Hire Date:

• Job Title:

• Did the Injured Employee seek additional medical assistance from a hospital or physican?

  Yes

  No

• Name of Physican or Hospital:

• Address:

• Phone Number:

• Employee was peforming work for:

  Select CPA North CPA South CPA Construction CPA O and M Peoples Natural Gas

  • CPA North
  • CPA South
  • CPA Construction
  • CPA O and M
  • Peoples Natural Gas

• Injured Employee's Foreman:

• Any Witnesses?

  Yes

  No

• Name of Witness:

• Injured Person Jobsite Location:
  Address

• Nearest Medical Facility:

Injury Classification:

• Type of Injury:

  Select Abrasion Laceration Burn Fracture Bruise Head Injury/Concussion Sprain/Strain Spinal Cord Eye Injury

  • Abrasion
  • Laceration
  • Burn
  • Fracture
  • Bruise
  • Head Injury/Concussion
  • Sprain/Strain
  • Spinal Cord
  • Eye Injury

• Body Part affected:

• Rate the Pain from a Scale of 1-10:

Employee Statement:

• Explain What happened in your own words:

Hazard Classification:

• What is the nature of the injury?

  Select Slips, Trips, Falls Struck By Caught in/ Between Electrical Shock Burn Fires/Explosion Trench Collapse Equipment Related Rollover/ Crushing Repetitive Motion Excessive Hot Temperatures Excessive Cold Temperatures Excessive Noise Exposure Respiratory Diseases

  • Slips, Trips, Falls
  • Struck By
  • Caught in/ Between
  • Electrical Shock
  • Burn
  • Fires/Explosion
  • Trench Collapse
  • Equipment Related
  • Rollover/ Crushing
  • Repetitive Motion
  • Excessive Hot Temperatures
  • Excessive Cold Temperatures
  • Excessive Noise Exposure
  • Respiratory Diseases

Root Cause Investigation

• 1. What Happened?

• 2. Why did this happen? (Direct Cause)

• 3. Why did #2 happen? (unsafe act/condition/indirect cause)

• 4. Why did this unsafe act/condition/indirect cause happen?

• Root Cause of the Injury:

Corrective Actions

• What can we do correct the root cause to prevent the injury from happening in the future?

• Attached Pictures:

  Media

• Employee Signature:

  Sign

• Safety Manager Signature:

  Sign