Injury Report

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Employee Information

• First name & Last name

• Social Security Number

• Street Address

• City

• State

• Zip code

• Telephone number

• Gender

• Job title

• Salary

• Date of Hire

• Date of Birth

• Marital Status

• Hours worked per week

Injury Information

• Exact location of injury

• Exact equipment involved at time of accident

• Operations Manager

• Supervisor on duty

• Shift

• Department

• Day and Time of accident

• Select date

  Date

• Floor Condition

• Mechanical Defect

• Safety Equipment Provided

• Safety Equipment in use

• Unsafe Act

Medical Attention (choose option)

• Medical Attention

  Select First Aid Medical Only Hospital Treatment (observation) Lost Work Day Restricted Work Case OSHA Recordable Fatality Medical Decline

  • First Aid
  • Medical Only
  • Hospital Treatment (observation)
  • Lost Work Day
  • Restricted Work Case
  • OSHA Recordable
  • Fatality
  • Medical Decline

• If Medical Attention Declined please sign

  Sign

• Estimated number of days on restricted work

• Estimated number of days away from work

• Attending physician

• Physician phone number

Preparers Name

• Add signature

  Sign