Employee’s 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:
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?
If yes, whom did you see?
Doctor’s phone number:
Has this part of your body been injured before?
__Yes __No
If yes, when?
Your signature:
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Supervisor’s Accident Investigation Form
Name of Injured Person
Date of Birth Telephone Number
(Select one) Male Female
State Zip
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? Doctor’s Name
Hospital Name
Recommended preventive action to take in the future to prevent reoccurrence.
Supervisor Signature Date
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click to sign
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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)
Sex: __Male
Job title at time of incident:
Part of body affected: (shade all that apply)
Nature of injury: (most
serious one)
This employee works:
__Regular full time
Regular part time
Months with
this employer
Months doing
this job:
__Abrasion, scrapes
__Broken bone
__Burn (heat)
__Burn (chemical)
Concussion (to the head)
Crushing Injury
__Cut, laceration, puncture
__Sprain, strain
Damage to a body system:
Step 2: Describe the incident
Exact location of the incident:
Exact time:
What part of employee’s workday?
__During meal period
__Entering or leaving work
__During break
__Doing normal work activities
__Working overtime Other
Names of witnesses (if any):
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Number of
Written witness statements:
Maps / drawings:
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 attachedsheets:
Step 3: Why did the incident happen?
Unsafe workplace conditions: (Check all that apply)
__Inadequate guard
Unguarded hazard
Safety device is defective
Tool or equipment defective
Workstation layout is hazardous
__Unsafe lighting
__Unsafe ventilation
__Lack of needed personal protective equipment
__Lack of appropriate equipment / tools Unsafe
__No training or insufficient training
Unsafe acts by people: (Check all that apply)
__Operating without permission
Operating at unsafe speed
__Servicing equipment that has power to it
Making a safety device inoperative
__Using defective equipment
__Using equipment in an unapproved way
__Unsafe lifting
__Taking an unsafe position or posture
Distraction, teasing, horseplay
__Failure to wear personal protective equipment
__Failure to use the available equipment / tools
Why did the unsafe conditions exist?
Why did the unsafe acts occur?
Is there a reward (such as “the job can be done more q
uickly”, 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?
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?
__Train the employee(s) __
Train the supervisor(s)
__Stop this activity __Guard the hazard
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:
Names of investigation team members:
Reviewed by:
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