Housekeeping Injury Report
Date of Report
Time of Report
Employee Name
Employee ID
Position/Department
Supervisor
Date of Injury
Time of Injury
Location of Incident
Describe How Injury Occurred
Type of Injury
Part of Body Injured
Was First Aid Administered?
Yes
No
If Yes, by Whom?
Was Incident Reported to Supervisor?
Yes
No
Witness(es) (Name & Contact)
Additional Comments
Employee Signature
Date
Supervisor Signature
Date