Safety & Fleet

Employee Injury Report (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. *

BACK part of body affected: *

Back of head Left back shoulder Right back shoulder Back of neck Upper back Lower back Left tricep Right tricep Left elbow Right elbow Glutes Left hamstring Right hamstring Left Kneepit Right Kneepit Left back calf Right back calf Left Ankle Right Ankle Left Heel Right Heel Right posterior forearm Left posterior forearm No injury

FRONT part of body affected: *

Forehead Face Right knee Right bicep Neck Collar bone Chest Left bicep Right calf Left forearm Left Foot Stomach Left calf Right Foot Right forearm Left hand Left knee Right hand Right front shoulder Left front shoulder Rt quadricep (thigh) Groin No injury

Nature of injury: (most serious one) *

Abrasion, scrapes Amputation Broken Bone Bruise Burn (heat) Burn (chemical) Crushing injury Hernia Illness Sprain, strain Cut Laceration Puncture Damage to a body system Struck on the head Other

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:

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