Workers’ Injury Report
Date of Report
Reported By
Worker's Name
Position/Job Title
Date of Injury
Time of Injury
Location of Incident
Description of Incident
Nature of Injury (body part affected, type of injury, etc.)
Describe What the Worker Was Doing
Witnesses (Names & Contact Information)
Immediate Actions Taken
Was Medical Attention Provided?
Yes
No
If Yes, Where?
Additional Notes