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