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How to write your own Employee Injury Report Form

You can create your customized editable version of this contract document using Human Resources Contract Pack. Follow these steps to get started.


Use the Employee Injury Report Form when an accident or injury occurs on the job. This form outlines what happened and what steps were taken, including supervisor signoffs.
Document Length: 2 Pages
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1. Get Human Resources Contract Pack, which includes this business contract document.

We include this Employee Injury Report Form in editable Word format that can be customized using your office software.

2. Download and install after ordering.

Once you have ordered and downloaded your Human Resources Contract Pack you will have all the content you need to get started.

3. Customize the contract template with your information.

You can customize the contract document as much as you need. You can also use the included Wizard software to automate name/address data merging.

Employee Injury Report Form

How to write my Employee Injury Report Form document

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

The complete Employee Injury Report Form - with the actual formatting and layout - is available in this Contract Pack.
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Proposal Kit
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Related documents may be used in conjunction with this document depending on your situation. Many related documents are intended for use as part of a contract management system.

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