Free Workplace Injury Report Form Template
Workplace Injury Report Form
By completing this Workplace Injury Report Form, you contribute to our commitment to safety. Prompt and accurate reporting ensures a secure working environment for everyone.
Employee Information
|
Employee Name: |
[Name] |
|
Employee ID: |
|
|
Department/Team: |
|
|
Job Title: |
|
|
Date of Birth: |
|
|
Date of Hire: |
Injury Details
|
Date and Time of Incident: |
[Month Day, Year], [Time] |
|
Location of Incident: |
|
|
Description of Incident: |
|
|
Nature of Injury/Illness: |
|
|
Body Part(s) Affected: |
|
|
Equipment/Tools Involved: |
Witness Information
|
Name of Witness 1: |
[Name] |
|
Contact Number: |
|
|
Email Address: |
|
|
Statement: |
|
|
Name of Witness 2: |
|
|
Contact Number: |
|
|
Email Address: |
|
|
Statement: |
Medical Treatment
|
Immediate First Aid: |
Applied ice pack to the injured ankle. |
|
Medical Facility Visited: |
|
|
Treatment Received: |
|
|
Follow-up Medical Care: |
Contributing Factors
|
Unsafe Conditions: |
Oil spilled on the floor near the machine |
|
Equipment Failure: |
|
|
Lack of Training: |
|
|
Other Factors: |
Corrective Actions Taken:
|
Area cleaned, wet floor signs placed. |
Employee’s Comments:
Report Prepared By:
[Your Name]
[Job Title]
[Date]
