Occupational Illness Reporting Form
Employee Information
Full Name
Employee ID
Department
Position
Contact Information
Illness Details
Date of Illness Onset
Date Reported
Type of Illness
Describe Symptoms
Work Activity/Task at Onset
Medical Diagnosis (if available)
Physician/Healthcare Provider
Additional Information
Witnesses (if any)
Reported to (Supervisor/Manager Name)
Actions Taken / Recommendations