Employee Report Of Occupational Injury

To Be Completed By the Employee Immediately.

Employee(Required)

First Last

Department(Required)

Shift(Required)

Location of Incident (be specific):(Required)

Date Reported(Required)

Time Reported(Required)

Reported to Whom(Required)

Name of Witness (es)

Are Witness Reports Completed?

Describe in detail the events leading to your injury, accident or occurrence.(Required)

What actions can be taken to prevent this event from recurring?(Required)

Did you receive any medical treatment or first aid?(Required)

If yes, please describe. Also, provide name and address of Treating Practitioner, Clinic and/or Hospital.

Signature(Required)

Date(Required)

Employee Report of Occupational Injury