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Employee Injury Report Date Reported: Current Date. Employee: First Last Department: Department Supervisor: Supervisor Date / Time of Injury Insert Injury Date and Time. Employee Job Information Position: Contract Job Title Number of Months in Current Position: Date of Hire: Work Type: Hourly ? Salary ? Shift Type: Day ? Night ? Swing ? Other ? Supervisor must complete the following form and file it with the Human Resources Department.

Description of Incident / Injury Describe the injury as well as the events or what happened to cause this injury. Attach additional pages if necessary.

Witnesses Did anyone witness the incident and/or injury? Yes ? No ? Name(s) of Witnesses:

Care Taken / Aid Rendered First Aid: ? Hospital / Urgent Care: ? Primary Care Physician / Clinic: ? Ambulance: ? No action taken: ? Other: ?

Hospital / Physician Information: (Name, Address, Phone) Notes:

Supervisor Signature Date

For Office Use Only

Recieved By signator, authorized signature or signer

Human Resources Manager Date

Company Name