Construction Site Workers’ Compensation Incident Report

Full Name Employee ID/Number Job Title Contact Number Date of Incident Time of Incident Location of Incident Supervisor Name Witness(es) Name(s) Description of Incident Cause of Incident (if known) Description of Injury/Illness Part(s) of Body Affected Was First Aid Given? Yes No Was Medical Treatment Sought? Yes No If Yes, Name of Medical Provider Equipment or Tools Involved Corrective Actions Recommended Additional Comments Report Completed By Date Signature