Employee's Report of Injury Form

• Site conducted

  Select

• I am reporting a work related

  Injury

  Illness

  Near Miss

• Your Name

• Job Title

• Supervisor

• Conducted on

  Date
• Location
  Address

• Instructions: Employees shall use this form to report all work related injuries, illnesses, or "near miss" events (which could have caused an injury or illness) — no matter how minor. This helps us to identify and correct hazards before they cause serious injuries. This form shall be completed by employees as soon as possible and given to a supervisor for further action.

undefined

• Have you told your supervisor about this injury/near miss?

  Yes

  No

• Date and time of injury/near miss

  Date

• Names of witnesses (if any)

• Where, exactly, did it happen?

• What were you doing at the time?

• Describe step by step what led up to the injury/near miss. (continue on the back if necessary):

• What could have been done to prevent this injury/near miss?

• What parts of your body were injured? If a near miss, how could you have been hurt?

• Did you see a doctor about this injury/illness?

  Yes

  No

• Whom did you see?

• Doctor's phone number

• Date and Time

  Date

• Has this part of your body been injured before?

  Yes

  No

• When

• Your Name and Signature

  Sign

• Supervisor Name and Signature

  Sign