Employees Report of Injury Form

Instructions: Employees shall use this form to report all work related injuries, illnesses, or
near miss events (which could have caused an injury or illness) no matter how minor. This
helps us to identify and correct hazards before they cause serious injuries. This form shall be
completed by employees as soon as possible and given to a supervisor for further action.

I am reporting a work related: Injury Illness Near miss

Your Name:
Job title:
Supervisor:
Have you told your supervisor about this injury/near miss? Yes No
Date of injury/near miss: Time of injury/near miss:

Names of witnesses (if any):

Where, exactly, did it happen?

What were you doing at the time?

Describe step by step what led up to the injury/near miss. (continue on the back if necessary):

What could have been done to prevent this injury/near miss?

What parts of your body were injured? If a near miss, how could you have been hurt?

Did you see a doctor about this injury/illness? Yes No

If yes, whom did you see? Doctors phone number:

Date: Time:
Has this part of your body been injured before? Yes No
If yes, when? Supervisor:
Your signature: Date:
 Supervisors Accident Investigation Form

Name of Injured Person

Date of Birth Telephone Number

Address
City State Zip
(Circle one) Male Female

What part of the body was injured? Describe in detail.

What was the nature of the injury? Describe in detail.

Describe fully how the accident happened? What was employee doing prior to the event? What
equipment, tools being using?

Names of all witnesses:

Date of Event Time of Event

Exact location of event:
What caused the event?

Were safety regulations in place and used? If not, what was wrong?

Employee went to doctor/hospital? Doctors Name

Hospital Name
Recommended preventive action to take in the future to prevent reoccurrence.

Supervisor Signature Date

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 Incident Investigation Report
Instructions: Complete this form as soon as possible after an incident that results in serious injury or illness.
(Optional: Use to investigate a minor injury or near miss that could have resulted in a serious injury or illness.)

This is a report of a: Death Lost Time Dr. Visit Only First Aid Only Near Miss

Date of incident: This report is made by: Employee Supervisor Team Other

Step 1: Injured employee (complete this part for each injured employee)
Name: Sex: Male Female Age:
Department: Job title at time of incident:
Part of body affected: (shade all that apply) Nature of injury: (most This employee works:
serious one) Regular full time
Abrasion, scrapes Regular part time
Amputation Seasonal
Broken bone Temporary
Bruise
Burn (heat) Months with
Burn (chemical) this employer
Concussion (to the head) Months doing
Crushing Injury this job:

Cut, laceration, puncture
Hernia
Illness
Sprain, strain
Damage to a body system:
Other

Step 2: Describe the incident

Exact location of the incident: Exact time:
What part of employees workday? Entering or leaving work Doing normal work activities
During meal period During break Working overtime Other
Names of witnesses (if any):

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Number of Written witness statements: Photographs: Maps / drawings:
attachments:
What personal protective equipment was being used (if any)?

Describe, step-by-step the events that led up to the injury. Include names of any machines, parts, objects, tools, materials
and other important details.

Description continued on attached sheets:

Step 3: Why did the incident happen?

Unsafe workplace conditions: (Check all that apply) Unsafe acts by people: (Check all that apply)
Inadequate guard Operating without permission
Unguarded hazard Operating at unsafe speed
Safety device is defective Servicing equipment that has power to it
Tool or equipment defective Making a safety device inoperative
Workstation layout is hazardous Using defective equipment
Unsafe lighting Using equipment in an unapproved way
Unsafe ventilation Unsafe lifting
Lack of needed personal protective equipment Taking an unsafe position or posture
Lack of appropriate equipment / tools Distraction, teasing, horseplay
Unsafe clothing Failure to wear personal protective equipment
No training or insufficient training Failure to use the available equipment / tools
Other: Other:

Why did the unsafe conditions exist?

Why did the unsafe acts occur?

Is there a reward (such as the job can be done more quickly, or the product is less likely to be damaged) that may
have encouraged the unsafe conditions or acts? Yes No
If yes, describe:

Were the unsafe acts or conditions reported prior to the incident? Yes No

Have there been similar incidents or near misses prior to this one? Yes No

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Step 4: How can future incidents be prevented?
What changes do you suggest to prevent this incident/near miss from happening again?

Stop this activity Guard the hazard Train the employee(s) Train the supervisor(s)

Redesign task steps Redesign work station Write a new policy/rule Enforce existing policy

Routinely inspect for the hazard Personal Protective Equipment Other:

What should be (or has been) done to carry out the suggestion(s) checked above?

Description continued on attached sheets:

Step 5: Who completed and reviewed this form? (Please Print)

Written by: Title:

Department: Date:
Names of investigation team members:

Reviewed by: Title:

Date: