Information about the employee

Full name


Date of birth
Date hired


Information about the physician or other health care professional

Name of physician or other health care professional

Was treatment given away from the worksite?

Address where treatment was given

Was employee treated in an emergency room?

Was employee hospitalized overnight as an in-patient?

Information about the case

Case number from the log

Date of injury or illness
Time employee began work
Estimated time of event (leave blank if time cannot be determined)

What was the employee doing before the incident occurred? Describe the activity, as well as the tools, equipment or material the employee was using.

What happened? Tell us how the the injury occurred.

Type of incident

Enter type of incident

Describe the injury or illness? Tell us the part of the body that was affected and how it was affected

What object or substance directly harmed the employee?

Upload photos of the incident

Did the employee die?

Date of death

Observations and comments

Full Name and Signature of Record Keeper