Title Page

  • Conducted on

  • Prepared by

  • Location

Injured Persons Details

  • Name:

  • Date of Birth:

  • Home Address:

  • Mobile Tel Number:

  • Work Address:

  • Work Tel Number:

  • Job Title:

  • Manager/Supervisor:

Incident Details

  • Date of Incident:

  • Time of Incident:

  • Date Reported:

  • Location of Incident:

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  • 1. Was the employee on duty?

  • 2. Did individual require medical attention?

  • Was individual transported to medical care?

  • Was individual transported via:

  • What type of vehicle?

  • 3. Individual was transported to:

  • Please state details:

  • 4. If YES to item #2, did the individual refuse medical care?

  • Please get the employee to sign the section below to state that they refused treatment.

  • Add signature

  • 5. Was employee in his/her assigned area?

  • 6. Did employee cease work due to incident?

  • What time did work cease?

  • 7. Is this a NEW injury?

Incident Facts

  • 1. Description of incident (state all facts clearly using individual’s own words):

  • 2. Body part affected/impacted:

  • 3. Needlestick/Sharp/Bloodborne Pathogens Exposure Incident?

Witnesses

    Witness
  • Name

  • Home Phone Number:

  • Address:

Signature of injured person

  • (By signing this form, the injured person certifies that the information provided is true to the best of their knowledge)

  • Add signature

Signature of Employee’s Supervisor

  • (PLEASE NOTE: SIGNING THIS FORM IS NOT AN ADMISSION OF TKL LIABILITY)

  • Add signature

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.