EMPLOYEE’S FIRST REPORT OF INJURY FORM

INSTRUCTIONS Using this form, employees shall report all work-related accidents, injuries, illnesses, or unplanned events which could have resulted in an injury or illness. Once completed, this form shall be given to a manager for next steps.

I AM REPORTING A WORK RELATED:	INJURY	ILLNESS	NEAR MISS

YOUR NAME	SUPERVISOR NAME	DATE OF REPORT
JOB TITLE	Has your supervisor been made aware of this incident?

LOCATION OF INCIDENT	DATE OF INCIDENT	TIME
WITNESSES if any
INCIDENT DESCRIPTION Describe tasks being performed and sequence of events. Attach additional pages as necessary.
What could nave 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?

Was medical treatment necessary?	IF YES, NAME OF HOSPITAL / PHYSICIAN:
YES	NO
DATE OF VISIT	TIME OF VISIT	HOSPITAL / PHYSICIAN PHONE

Has this part of your body been injured before?	YES	NO	If YES, when?

Do you have other employment?	YES	NO	Company Name

EMPLOYEE SIGNATURE	DATE	SUPERVISOR SIGNATURE	DATE

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