Employee's Report of Injury Form - Free Download | Page 3
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Employee's Report of Injury Form Page 3
Employee
3
Incident Investigation Report
Instructions: Complete this form as soon as possible after an incident that results in serious injury or illness.
(Optional: Use to investigate a minor injury or near miss that could have resulted in a serious injury or illness.)
This is a report of a: Death Lost Time Dr. Visit Only First Aid Only Near Miss
Date of incident: This report is made by: Employee Supervisor Team Other_________
Step 1: Injured employee (complete this part for each injured employee)
Name:
Sex: Male Female
Age:
Department: Job title at time of incident:
This employee works:
Regular full time
Regular part time
Seasonal
Temporary
Months with
this employer
Months doing
this job:
Part of body affected: (shade all that apply)
Nature of injury: (most
serious one)
Abrasion, scrapes
Amputation
Broken bone
Bruise
Burn (heat)
Burn (chemical)
Concussion (to the head)
Crushing Injury
Cut, laceration, puncture
Hernia
Illness
Sprain, strain
Damage to a body system:
Other ___________
Step 2: Describe the incident
Exact location of the incident:
Exact time:
What part of employee’s workday Entering or leaving work Doing normal work activities
During meal period During break Working overtime Other___________________
Names of witnesses (if any):
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Employee's Report of Injury Form