Title Page
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Employee name
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Job title
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Supervisor name
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Date and time of reporting
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Location
Employee Report of Injury Form
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I am reporting a work-related...
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Date and time of injury
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Name of witnesses (if any)
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Have you told your supervisor about this injury?
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Where did the injury happen?
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What were you doing at the time?
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Describe in detail what led up to the injury.
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What could have been done to prevent this injury?
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What parts of your body were injured?
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Did you see a doctor about this injury?
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Doctor's name
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Doctor's contact number
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Date and time of consultation
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Has this part of your body been injured before?
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When did this happen?
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Date and time of illness
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Name of witnesses (if any)
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Have you told your supervisor about this illness?
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Where did the illness happen?
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What were you doing at the time?
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Describe in detail what led up to the illness.
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What could have been done to prevent this illness?
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What parts of your body were ill?
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Did you see a doctor about this illness?
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Doctor's name
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Doctor's contact number
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Date and time of consultation
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Has this part of your body been ill before?
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When did this happen?
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Date and time of near-miss
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Name of witnesses (if any)
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Have you told your supervisor about this near-miss?
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Where did the near-miss happen?
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What were you doing at the time?
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Describe in detail what led up to the near-miss.
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What could have been done to prevent this near-miss?
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How could you have been hurt?
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Name and signature of employee
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Name and signature of supervisor
