Personal Injury Report EMPLOYEE INFORMATION Employee Name * First Name Last Name Date of Birth * MM DD YYYY Phone (###) ### #### Supervisor Name * First Name Last Name Injury/Accident Information Date of injury * MM DD YYYY Time of injury * Hour Minute Second AM PM Time employee began work * Hour Minute Second AM PM Jobsite Address where incident occurred * Where on the jobsite did the injury occur? * Witness to Incident: * First Name Last Name Phone (###) ### #### Witness to Incident: * First Name Last Name Phone (###) ### #### Was the supervisor notified immediately? * Yes No What instructions did they give? * What was the employee doing just before the incident occured? Describe the activity, as well as the tools, equipment, or material the employee was using. Be specific. * What happened? Tell us how the injury occurred. * What was the injury or illness? Tell us the part of the body and how it was affected. * What object or substance directly harmed the employee? * How can this be prevented in the future? * Was the employee treated for injury on the job site? * Yes No If YES, How was employee treated for injury? * Was the employee treated for injury away from the job site? * Yes No If YES, at what Facility? * Address * What treatment did employee receive: * “I certify that my answers for this incident report are true and complete to the best of my knowledge. I understand that this form may contain sensitive information relating to employee health and must be used in a manner that protects the confidentiality of the employee to the extent possible.” Completed By * First Name Last Name Title Phone (###) ### #### Date of Form Fill Out: * MM DD YYYY Submitted
