Occupational Injury Statement Form
Employee Information
Name
Employee ID
Job Title
Department
Supervisor
Injury Details
Date of Injury
Time of Injury
Location of Incident
Describe How the Injury Occurred
Type of Injury
Part(s) of Body Injured
Witness Information
Witness Name
Contact Information
Medical Details
Was First Aid Provided?
Yes
No
Medical Treatment Location
Date Reported
Reported To
Employee Statement
Signature
Employee Signature
Date