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Injury Report
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* Indicates required question
Name
*
Your answer
Person(s) involved in the injury (not limited to those injured)
*
Your answer
Witness(es)
*
Your answer
Date of Injury
*
MM
/
DD
/
YYYY
Time of Injury
*
Time
:
AM
PM
Location of injury (i.e. venue, etc.):
*
Your answer
Type Of Injury (Broken Bone, Sprain, Cut, Etc.):
*
Your answer
Describe the situation and events that occured, including pertinent details leading up to the injury:
*
Your answer
List all equipment, machinery, materials, etc. being used at the time of the injury:
*
Your answer
Did the employee receive medical treatment?
*
Yes
No
If YES, what treatment, by whom (e.g. off-duty professional, specific hospital, etc.)?
Your answer
Did they take an ambulance?
*
Yes
No
Was the employee hospitalized overnight?
*
Yes
No
Are there ANY other details we should be aware of? Please be as thorough as possible.
*
Your answer
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