Free Cleaning Services Injury Report Form Template

Cleaning Services Injury Report Form

Instructions: Please complete this form accurately and submit it to HR within 24 hours of the incident.

General Information

Employee Name:

Employee ID:

Date of Incident:

Time of Incident:

Job Title:

Department:

Supervisor:

Injury Details

Type of Injury:

Body Part Injured:

Nature of Injury:

Severity of Injury:

Description of Incident:

Witness Name:

Contact Information:

Immediate Action Taken

First Aid Provided:

  • Yes

  • No

Medical Attention Required:

  • Yes

  • No

Emergency Services Called:

  • Yes

  • No

If Yes, Which Services:

Ambulance

Additional Information/Notes:

Recommendations to Prevent Future Incidents:

Employee Signature:

[Month Day, Year]

Supervisor Signature:

[Month Day, Year]

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