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:
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? Doctor’s phone number:
Date: Time:
Has this part of your body been injured before? Yes No
If yes, when? Supervisor:
Your signature: Date:
Supervisor’s 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? Doctor’s Name ___________________________________________
Hospital Name __________________________________________
Recommended preventive action to take in the future to prevent reoccurrence.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
______________________ ___________
Supervisor Signature Date
2
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
Months with
Burn (heat)
this employer
Burn (chemical)
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 employee’s workday? Entering or leaving work Doing normal work activities
During meal period During break Working overtime Other___________________
Names of witnesses (if any):
3
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
4
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:
