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Injury Information Form
Complete for any work-related injury or illness.
Original PDF form also available
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Injured Employee
Full Name
*
Employee ID / Badge #
Job Title
Department
Date of Hire
Employee Phone
Injury Details
Date of Injury
*
Time of Injury
Location of Injury
*
Body Part Affected
*
Select body part
Head / Skull
Face
Eye(s)
Ear(s)
Neck
Shoulder(s)
Upper Arm
Elbow
Forearm
Wrist
Hand / Fingers
Chest / Ribs
Upper Back
Lower Back
Abdomen
Hip
Thigh
Knee
Lower Leg
Ankle
Foot / Toes
Multiple
Other
Side of Body
Select
Left
Right
Both
N/A
Nature of Injury
*
Select type
Abrasion / Scrape
Bruise / Contusion
Burn
Cut / Laceration
Fracture / Break
Sprain / Strain
Chemical exposure
Eye injury
Hearing loss
Illness / Illness exposure
Other
Cause of Injury
Select cause
Struck by object
Struck against object
Caught in / between
Fall — same level
Fall — different level
Overexertion / lifting
Repetitive motion
Chemical / substance contact
Vehicle accident
Other
Object / Equipment Involved
Description of Injury
*
Medical Treatment
First Aid Given on Site
Select
Yes
No
Medical Facility
Treating Physician
Date of Treatment
Lost Time Expected
Select
No lost time
Restricted duty
1–3 days
4–14 days
15+ days
Unknown
Expected Return to Work
Witnesses
Witness 1 — Name & Phone
Witness 2 — Name & Phone
Supervisor Information
Supervisor Name
*
Supervisor Phone
Supervisor Notified
Reported By
Name
*
Phone
*
Email
Submit Injury Form
