Workers’ Compensation Injury Report Form
Employee Information
Employee Name
Employee ID
Department
Job Title
Supervisor
Incident Information
Date of Incident
Time of Incident
Location of Incident
Describe the Incident
Injury Information
Nature of Injury
Body Part(s) Affected
Was Medical Treatment Provided?
Yes
No
If Yes, Provide Details
Witness Information
Witness Name(s)
Witness Statement(s)
Additional Comments
Report Date
Signature