Printable Business Form Templates
Injury Report Business Form Template

Injury Report

Fields: employee name, department, title, age, sex, date of injury, time of injury

Did the injury occur while performing a work related activity?

Describe the injury. What body parts were affected? What kind of injury?

Describe what was happening when the injury occurred.

Was any first aid given at the scene? If so, what type?

Were there any witnesses? If so, please provide their names.

If patient was transported to hospital or clinic, give the info:

Name of hospital or clinic:

Medical provider(s):

Describe the treatment provided.

Did the employee miss any work?

If yes, please provide dates
Has the employee returned to work?

Additional Notes:

Date:_________ Employee Signature: ___________________________

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