Free Employee Injury Report Form Template
Employee Injury Report Form
Please fill out this form to report any workplace injury for documentation and follow-up.
Employee Information
Name
Job Title
Department
Date of Report
Injury Details
Date and Time of Injury
Location of Injury
Describe the injury and how it occurred
Witness Information
Were there any witnesses?
If yes, provide details:
Name
Phone number
Treatment and Follow-Up
Was medical treatment required?
If yes, specify
Treatment Facility/Provider
Employee Acknowledgment
I certify that the above information is accurate to the best of my knowledge.
Name:
Date:
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