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    Injury Report Form

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    Please note: This sample Injury Report Form is provided for you by HR.com as a free service. The free hr templates and forms on this site are general in nature and not based on the laws of any specific state or other jurisdiction. Prior to using these policies or forms, we recommend that you consult with an attorney or other expert knowledgeable in the laws of the applicable jurisdiction and the specific intended use of those documents.

     

    Injury Report Form

     

    [Company Name]

     

    Employee Name:_______________________________________________________

     

    SS#:___________________________________

     

    Job Title:______________________________________________________________

     

    Department:___________________________________________________________

     

    Date/Time of Incident:_________________________________

     

    Location:_______________________________________________________________

     

    Date/Time reported:____________________________________

     

    Reported to:_____________________________________________________________

     

    Description of incident:___________________________________________________

    ________________________________________________________________________

    ________________________________________________________________________

    ________________________________________________________________________

    ________________________________________________________________________

     

    Description of injury:

    ________________________________________________________________________

    ________________________________________________________________________

    ________________________________________________________________________

    ________________________________________________________________________

     

    Recorded on OSHA Form?__________

     

    Where was treatment given?_______________________________________________

    What type of treatment was given?__________________________________________

    Is employee able to return to work?_________________________________________

    If yes, when?_____________________________________________________________

    If no, how many days off are required:_______________________________________

     

     

     

     

     

    __________________________________________________________________________

    Prepared by (print)

     

    __________________________________________________________________________

    Signature

     

    ____________________________

    Date



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