Healthcare Workplace Injury Report Form
Employee Name
Department/Unit
Position/Job Title
Date of Injury
Time of Injury
Location of Incident
Describe How the Injury Occurred
Type of Injury
Body Part(s) Injured
Witness Name(s)
Immediate Action Taken
Was Medical Attention Provided?
Yes
No
Reported to Supervisor?
Yes
No
Name of Supervisor
Signature
Date