Employee Injury Report (copy) (copy)

First 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 form should be completed by

I am reporting a work related: *

Injury Illness Near Miss Other

Business Name *

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Location/Facility *

General Manager *

General Manager Email *

example@example.com

Teammate Name *

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Teammate Email *

example@example.com

Your Phone Number *

Date and Time of injury/near miss: *

Exact location of the incident (address location) *

What State did the Incident Occur? *

Was Supervisor Notified immediately? *

Yes No

What happened? 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. *

Names of witnesses (if any) *

What personal protective equipment was being used (if any)? *

Photo of Injury

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Photo of surrounding area, any object that caused the injury, any vital area that needs photographed (DO NOT TAKE PICTURES OF BODY PARTS) *

Was first aid done at the time of incident? *

If first aid was done at time of incident, by whom?

Does anyone need to seek further Medical Treatment *

Reported by Name (Please Print) *

Reported by Signature *

Date: