"Employee's Report of Injury Form"

Employee's Report of Injury Form is a 5-page legal document that was released by the U.S. Department of Labor - Occupational Safety & Health Administration and used nation-wide.

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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:
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)
Months doing
Concussion (to the head)
this job:
Crushing Injury
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:
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