Injury Report Form

Today's Date(Required)

Injured Employee Name(Required)

First Last

Time Employee Began Work On Date of Injury(Required)

Date of Injury(Required)

Time of Injury(Required)

Address Where Injury Occurred(Required)

Street Address City State / Province / Region ZIP / Postal Code

Weather Conditions(Required)

What was the employee doing just before the injury occurred?(Required)

Describe the activity as well as any tools, equipment, or material the employee was using.

What Happened?(Required)

What was the injury or illness?(Required)

What part of the body was affected and how was it affected?

What object or substance was directly related to the injury?(Required)

If treatment was received off-site, what was the name and location of the health care provider?

Form Completed By(Required)

First Last

Upload photos of injury if applicable.

Max. file size: 256 MB.