Injury Report Form

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Injury Report
Employee Name
Department
Title
Age
Sex
Date of Injury
Time of Injury
Did the injury occur while performing a work related activity?
Describe the injury. What body parts were affected? What kind of injury?
Describe what was happening when the injury occurred.
Was any first aid given at the scene? If so, what type?
Were there any witnesses? If so, please provide their names.
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Injury Report
Employee Name
Department
Title
Age
Sex
Date of Injury
Time of Injury
Did the injury occur while performing a work related activity?
Describe the injury. What body parts were affected? What kind of injury?
Describe what was happening when the injury occurred.
Was any first aid given at the scene? If so, what type?
Were there any witnesses? If so, please provide their names.
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If patient was transported to hospital or clinic, give the info:
Name of hospital or clinic
Medical Provider(s)
Address
Phone
Describe the treatment provided.
Did the employee miss any work?
If yes, please provide dates
Has the employee returned to work?
Additional Notes:
Date
Employee Signature
Date
Supervisor Signature
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