Select Page

Injury Report Email Format

 

 

 

 

 

 INJURY REPORT

 

 

 

 

 

 

 

Brand

[617]

Store

 [683]

Date

[619]

Name of Manager Completing Report

[620]

Phone Number if Manager Completing Report

[285]
INJURED PERSON’S INFORMATION
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  
 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
Name of Involved Party [634]
Employee? [635]
Address [381]
Witness 2  
Name of Involved Party [687]
Employee? [688]
Address [689]
Witness 3  
Name of Involved Party [692]
Employee? [693]

Address

 [694]