Manufacturing Line Workers’ Compensation Report Form
Employee Information
Full Name
Employee ID
Department
Position/Role
Contact Number
Incident Details
Date of Incident
Time of Incident
Location of Incident
Description of Incident
Injury Details
Type of Injury
Body Part(s) Affected
Medical Attention Received?
Yes
No
If yes, please describe treatment
Witness Information
Witness Name(s)
Witness Contact
Additional Comments
Supervisor/Manager Information
Supervisor Name
Contact Number
Date Report Filed