Injury Report Email Format
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INJURY REPORT |
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Date
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[619]
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Name of Manager Completing Report
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[620]
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Phone Number if Manager Completing Report
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[285]
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| INJURED PERSON’S INFORMATION |
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| Person injured |
[621] |
| Injured Name |
[622] |
| Injured Phone Number |
[294] |
| Injured Address |
[623] |
| Type of Injury |
[295] |
| Body part employee claims were injured? |
[286] |
| INCIDENT INFORMATION |
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| Manager on Duty at the time of Incident |
[624] |
| Date of Incident |
[282] |
| Time of Incident |
[300] |
| Date Incident was reported |
[297] |
| Location of Incident |
[299] |
| Describe the Incident In Detail |
[301] |
| Photo 1 of Incident |
 |
| Photo 2 of Incident |
 |
| What Conditions or action contributed |
[630] |
| Was 911 Called |
[625] |
| Has injured person been to the doctor or received medical treatment as a result of this incident? If yes, please provide the name and contact info for the doctor/hospital. |
[626] |
| Name of Dr at Hospital |
[629] |
| Address of Hospital |
[627] |
| Is it likely that the employee will require medical treatment in the future? |
[631] |
| Witness 1 |
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| Name of Involved Party |
[634] |
| Employee? |
[635] |
| Address |
[381] |
| Witness 2 |
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| Name of Involved Party |
[687] |
| Employee? |
[688] |
| Address |
[689] |
| Witness 3 |
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| Name of Involved Party |
[692] |
| Employee? |
[693] |
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Address
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[694] |
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