Workers’ Compensation Injury Report
Employee Information
Full Name
Employee ID
Job Title
Department
Incident Details
Date of Injury
Time of Injury
Location
Describe the Injury
How did the injury occur?
Medical Treatment
Date First Treated
Treating Physician/Provider
Treatment Facility Name and Address
Date Returned to Work
Witness Information
Witness Name(s)
Supervisor/Employer
Supervisor Name
Date Reported