Cleaning Services Injury Report Form
Cleaning Services Injury Report Form
Instructions: Please complete this form accurately and submit it to HR within 24 hours of the incident.
General Information
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Employee Name: |
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Employee ID: |
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Date of Incident: |
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Time of Incident: |
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Job Title: |
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Department: |
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Supervisor: |
Injury Details
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Type of Injury: |
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Body Part Injured: |
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Nature of Injury: |
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Severity of Injury: |
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Description of Incident: |
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Witness Name: |
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Contact Information: |
Immediate Action Taken
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First Aid Provided: |
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Medical Attention Required: |
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Emergency Services Called: |
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If Yes, Which Services: |
Ambulance |
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Additional Information/Notes: |
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Recommendations to Prevent Future Incidents: |
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Employee Signature:
[Month Day, Year]
Supervisor Signature:
[Month Day, Year]
