Title Page
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
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Attention: This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possible while the information is being used for occupational safety and health purposes.
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This Injury and Illness Incident Report is one of the first forms you must fill out when a recordable work-related injury or illness has occurred. Together with the Log of Work-Related Injuries and Illnesses and the accompanying Summary, these forms help the employer and OSHA develop a picture of the extent and severity of work-related incidents.
Within 7 calendar days after you receive information that a recordable work-related injury or illness has occurred, you must fill out this form or an equivalent. Some state workers' compensation, insurance, or other reports may be acceptable substitutes. To be considered an equivalent form, any substitute must contain all the information asked for on this form.
According to Public Law 91-596 and 29 CFR 1904, OSHA's record keeping rule, you must keep this form on file for 5 years following the year to which it pertains. -
Completed by:
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Title:
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Phone:
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Date:
Information About the Employee
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Full Name:
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Address:
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Date of Birth:
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Date Hired:
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Male
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Female
Information about the physician or other health care professional
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Name of physician or other health care professional:
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If treatment was given away from worksite, where was it given?
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Facility:
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Address:
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Was employee treated in an emergency room?
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Was employee hospitalized overnight as an in-patient?
Information About the Case
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Case number from the Log (Transfer the case number from the Log after you record the case.)
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Date of injury or illness:
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Time employee began work:
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Time of event:
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Check if time cannot be determined
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What was the employee doing just before the incident occurred? Describe the activity, as well as the tools, equipment, or material the employee was using. Be specific. Examples: "climbing a ladder while carrying roofing materials", "spraying chlorine from hand sprayer", daily computer key-entry."
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What happened? Tell us how the injury occurred. Examples: "When ladder slipped on wet floor, worker fell 20 feet"; "Worker was sprayed with chlorine when gasket broke during replacement"; "Worker developed soreness in wrist over time."
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What was the injury or illness? Tell us the part of the body that was affected and how it was affected; be more specific than "hurt", "pain", or "sore". Examples: "strained back"; "chemical burn, hand"; "carpal tunnel syndrome."
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What object or substance directly harmed the employee? Examples: "concrete floor"; "chlorine"; "radial arm saw". If this question does not apply to the incident, leave it blank.
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If the employee died, when did the death occur?
