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