Title Page
Employee Information
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Name of Employee
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Employee Phone Number
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Employee Date of Birth
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Employee Home Address
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City
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State
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Zip
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Position
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Supervisor
Information
Incident Information
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Date and Time of Incident
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Time Employee Started Work
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Address Incident occurred
Address
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Street or Road
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City
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State
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Zip
Was an ambulance needed?
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Yes
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No
Type of Incident (please select one)
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Incident Only
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FIrst Aid
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Clinic
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Treating Physician
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Phone Number (if known)
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Hospital Name
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City
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State
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Phone Number
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Emergency Room
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Treating Physician
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Phone Number (if known)
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Hospital Name
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City
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State
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Phone Number
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Hospitalization
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Treating Physician
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Phone Number (if known)
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Hospital Name
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City
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State
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Phone Number
Body Parts Injured
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Body Part
Head and Neck
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Scalp
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Eyes
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Ears
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Mouth/Teeth
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Neck
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Face
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Skull
Upper Extremities
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Shoulder
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Left
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Right
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Upper Arm
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Left
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Right
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Elbow
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Left
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Right
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Forearm
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Left
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Right
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Wrist
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Left
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Right
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Hand
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Left
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Right
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Finger
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Left
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Right
Body
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Back
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Chest
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Abdomen
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Groin
Lower Extremities
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Hips
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Left
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Right
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Thigh
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Left
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Right
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Knee
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Left
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Right
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Leg
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Left
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Right
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Ankle
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Left
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Right
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Feet
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Left
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Right
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Toes
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Left
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Right
Equipment/Property
Equipment Usage
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Yes
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Type of Equipment
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Equipment Number
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Photo of equipment
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No
Incident Description
Please recreate the events leading up to the incident, the incident itself, and activity after the incident occurred. Be sure to be as detailed as possible. Attach pictures of the incident scene and try to gather multiple angles of the incident scene.
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Incident Description
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Photos
Witnesses
Were there any witnesses?
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Yes
Witness
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Name
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Phone
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Statement
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No
Completion
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Report Submitted by
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Select date
