Injury and Illness Incident Report Form
Date of Incident
Time of Incident
Location of Incident
Employee Name
Job Title
Department
Type of Incident
Injury
Illness
Near Miss
Other
Describe what happened
Describe the Injury/Illness
Body Part(s) Affected
First Aid / Medical Treatment Provided
Witness(es) (Name and Contact)
Name of Person Completing the Report
Date