Injury Report Form
This injury report form can be used to record work-related injuries,
causes, and actions taken to address them. It follows the Occupational
Safety and Health Administration (OSHA)’s framework for reporting
occupational injuries, illnesses, and incidents from an employee
perspective.
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Title Page
Employee name Text answer
Job title Text answer
Supervisor name Text answer
Date and time of reporting Date/time
Enter Date and Time:
/ /
: AM / PM
Location Text answer
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Employee Report of Injury Form
I am reporting a work-related... Select one
[ ] Injury
[ ] Illness
[ ] Near Miss
If answer is Injury Answer Question(s) 1.0, 1.1, 1.2,
1.3, 1.4, 1.5, 1.6, 1.7, 1.8, 1.9
1.0 - Date and time of injury Date/time
Enter Date and Time:
/ /
: AM / PM
1.1 - Name of witnesses (if any) Text answer
1.2 - Have you told your supervisor about this injury? Select one
[ ] Yes
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[ ] No
1.3 - Where did the injury happen? Text answer
1.4 - What were you doing at the time? Text answer
1.5 - Describe in detail what led up to the injury. Text answer
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1.6 - What could have been done to prevent this injury? Text answer
1.7 - What parts of your body were injured? Text answer
1.8 - Did you see a doctor about this injury? Select one
[ ] Yes
[ ] No
If answer is Yes Answer Question(s) 1.8.0, 1.8.1,
1.8.2
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1.8.0 - Doctor's name Text answer
1.8.1 - Doctor's contact number Text answer
1.8.2 - Date and time of consultation Date/time
Enter Date and Time:
/ /
: AM / PM
1.9 - Has this part of your body been injured before? Select one
[ ] Yes
[ ] No
If answer is Yes Answer Question(s) 1.9.0
1.9.0 - When did this happen? Text answer
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If answer is Illness Answer Question(s) 1.10, 1.11,
1.12, 1.13, 1.14, 1.15, 1.16, 1.17,
1.18, 1.19
1.10 - Date and time of illness Date/time
Enter Date and Time:
/ /
: AM / PM
1.11 - Name of witnesses (if any) Text answer
1.12 - Have you told your supervisor about this illness? Select one
[ ] Yes
[ ] No
1.13 - Where did the illness happen? Text answer
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1.14 - What were you doing at the time? Text answer
1.15 - Describe in detail what led up to the illness. Text answer
1.16 - What could have been done to prevent this illness? Text answer
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1.17 - What parts of your body were ill? Text answer
1.18 - Did you see a doctor about this illness? Select one
[ ] Yes
[ ] No
If answer is Yes Answer Question(s) 1.18.0,
1.18.1, 1.18.2
1.18.0 - Doctor's name Text answer
1.18.1 - Doctor's contact number Text answer
1.18.2 - Date and time of consultation Date/time
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Enter Date and Time:
/ /
: AM / PM
1.19 - Has this part of your body been ill before? Select one
[ ] Yes
[ ] No
If answer is Yes Answer Question(s) 1.19.0
1.19.0 - When did this happen? Text answer
If answer is Near Miss Answer Question(s) 1.20, 1.21,
1.22, 1.23, 1.24, 1.25, 1.26, 1.27
1.20 - Date and time of near-miss Date/time
Enter Date and Time:
/ /
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: AM / PM
1.21 - Name of witnesses (if any) Text answer
1.22 - Have you told your supervisor about this near-miss? Select one
[ ] Yes
[ ] No
1.23 - Where did the near-miss happen? Text answer
1.24 - What were you doing at the time? Text answer
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1.25 - Describe in detail what led up to the near-miss. Text answer
1.26 - What could have been done to prevent this near-miss? Text answer
1.27 - How could you have been hurt? Text answer
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Name and signature of employee Signature
Date: / /
Name and signature of supervisor Signature
Date: / /
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