Initial Injury Information
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Company
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Date of Injury
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Date Injury Reported to Supervisor
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Person Completing Report
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Type of Injury (Report Only, First Aid, or Medical)
Injured Employee Information
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Employee Name
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Job Title
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Start Time
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Employee Address
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Employee Phone Number
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Supervisor Name:
Incident Information
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Address/location where incident occurred
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Specific location of incident (e.g. loading dock)
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Location of Injury: Please be specific as to which body part that is injured
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Describe the circumstances causing the incident/injury/or near miss; please be specific
Personal Protective Equipment
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Hard Hat
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Safety Glasses
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Face Shield
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Cut Resistant Gloves
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Safety Toed Boots
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Long Pants
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Hearing Protection
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Fall Protection
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Other
Medical Provider Information
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Type of Clinic (Onsite Nurse, Urgent Care Facility, Emergency Room, Occupational Medicine, Other)
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Name of Medical Provider
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Address of Medical Provider
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Phone Number of Provider
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Did the employee receive a post-accident drug or alcohol test
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Where was employee sent for testing
Witness Information
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Name
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Title
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Phone #
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Name
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Title
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Phone #
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Name
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Title
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Phone #
Signature Page
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This report is to be filled out to the employee's full knowledge of the accident.
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I certify that the information provided on this report is true and complete to the best of my knowledge.
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Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against the company, submits an application, or files a claim containing a false or deceptive is guilty of insurance fraud.
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If I seek medical attention, I will notify the doctor that Bug Tussel, KES Excavating and Red Tail Towers, will accommodate medical restrictions for work-related incidents.
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I will contact the Safety Department or my Supervisor after each doctor visit and will follow all medical restrictions on and off the job.
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Employee Signature
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Date
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Supervisor Signature
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Date
