Workplace Incident/Injury Report
Report Completed By:
Department Phone No.
Full Name Employee ID Sex
Male ☐ Female ☐
Street Address Apt No.
City State Zip
Job Description/Title Hire Date Birthdate
Supervisors Name Department
Date of occurrence Address, Place & Location of Occurrence
Time Employee started work Time of event (if known) Case Number:
Were there any witnesses to the incident? If yes, Provide names:
Yes ☐ No ☐
What was the employee doing immediately before the event happened?
Describe activity, and any tools or materials that were used.
Was protective equipment available to the employee? Was protective equipment was protective equipment being used be the
employee at the time of the incident?
Yes ☐ No ☐ Yes ☐ No ☐
Please describe what happened?
Describe how the incident or injury took place (e.g. “Boxes were knocked down onto worker”).
What was the injury/illness?
Describe body part(s) affected, and how they are affected. (e.g. “Cut on upper left arm” or “Dislocated left shoulder”).
What specific object, item or person specifically harmed the employee?
(e.g. “Box cutter” Meat Slicer”)
Description of Medical Assistance
Did the injured employee see a doctor or go to the hospital? If yes, Was the employer’s portion of worker’s comp. form filled?
Yes ☐ No ☐ Yes ☐ No ☐
Date of Treatment: Name of attending doctor:
Facility or hospital name (if applicable) Facility or hospital phone number (if applicable)
Facility or hospital address (if applicable)
Was employee treated in an emergency room? Was employee stay overnight? Is employee still receiving treatment/care?
Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐
Comments and/or additional information
I certify the information I have provided on this form is true, correct and complete to the best of my knowledge.
Furthermore, I understand the information I have provided may be audited by the company or any of its
representatives. I understand that falsifying the document may be grounds for disciplinary action up to and
including termination of employment. In addition, I may be in violation of federal and/or state law and may be
subject to prosecution.
Employee’s Signature: __________________________________________________ Date: ___________________
I have reviewed this report and acknowledge its receipt.
Supervisor’s Signature: __________________________________________________ Date: ___________________