Title Page

INCIDENT INFORMATION

  • Date and time of incident:

  • Today's Date:

  • Location of incident:

JOB INFORMATION

  • Job Name:

  • Job Number:

  • Foreman Name:

  • Foreman Phone Number:

EMPLOYEE INFORMATION:

  • SSN:

  • Employee Home Address:

  • Employee Phone Number:

  • Birth Date:

  • Gender:

  • Marital Status:

  • Number of Dependents

  • Hire Date:

  • Job Title:

  • Employment Status:

  • Hourly Wage:

  • Weekly Hours:

  • Taxes are withheld for which state?

  • State:

  • Return to Work:

  • Full pay received on date of injury?

  • Start Time:

  • Time of Occurence:

  • Date Last Worked:

  • Date Returned to Work:

MEDICAL PROVIDER INFO:

  • Did Employee See a Medical Provider?

  • What Type of Medical Treatment:

  • Doctor's Name:

  • Facility Name:

  • Facility Address:

  • Ensure a Declination of Treatment form is filled out and sent with Injury Report.

  • Injury Type:

  • Enter OTHER injury type:

  • Part of Body:

  • Enter OTHER body part:

ACCIDENT INVESTIGATION

  • What was the employee doing when the incident occurred?

  • Were there any witnesses?

  • Please list the name(s) and address(es):

  • What was the cause of the injury?

  • Was the injury preventable?

  • How?

  • What corrective action is being taken to prevent this type of injury from reoccurring?

SIGNATURES

  • Injured Employee Signature:

  • Supervisor Signature:

  • Report Taken By:

PICTURES

  • Please provide pictures of incident scene. Attach additional pictures to email.

  • Picture 1:

  • Picture 2:

  • Picture 3:

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.