| Date of Injury | |
|---|---|
| Time of Injury | |
| Type and Brand of Device Involved | |
| Department or Work Area | |
| Description of Incident | |
| Job Title of Injured Employee | |
| How Incident Occurred | |
| Body Part Injured | |
| Actions Taken (e.g. treatment) | |
| Reported To | |
| Date Reported | |
| Supervisor/Reviewer | |
| Additional Comments |