Free Workplace Injury Report Form

Introducing the Workplace Injury Report Form Template from Template.net. This editable and customizable form streamlines incident documentation. Effortlessly tailor it to your company's needs. Editable in our AI Editor Tool for seamless customization. Simplify reporting procedures and prioritize workplace safety with this essential resource.

Employee Name:	[Name]
Employee ID:
Department/Team:
Job Title:
Date of Birth:
Date of Hire:

Date and Time of Incident:	[Month Day, Year], [Time]
Location of Incident:
Description of Incident:
Nature of Injury/Illness:
Body Part(s) Affected:
Equipment/Tools Involved:

Name of Witness 1:	[Name]
Contact Number:
Email Address:
Statement:
Name of Witness 2:
Contact Number:
Email Address:
Statement:

Immediate First Aid:	Applied ice pack to the injured ankle.
Medical Facility Visited:
Treatment Received:
Follow-up Medical Care:

Unsafe Conditions:	Oil spilled on the floor near the machine
Equipment Failure:
Lack of Training:
Other Factors:

Free Workplace Injury Report Form

Employee Information

Injury Details

Witness Information

Medical Treatment

Contributing Factors

Corrective Actions Taken:

Employee’s Comments:

Report Prepared By:

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