Employee Injury Report

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Report a workplace injury, accident, or safety incident.
Employee Information
Full Name*
First Last
Position*
Date*
MM slash DD slash YYYY
Supervisor*
Incident Details
Incident Date*
Month
Day
Year
Incident Time*

: Hours

Minutes

AM/PM
Brief Description of Accident*
Vehicle Information (If Applicable)
Company or Personal Vehicle*
Make/Model*
License Plate*
Injury Information
Injuries*
- Yes
- No
Description of Injuries*
Medical Treatment Received*
- Yes
- No
If yes, where
Police / Witness Information
Police Report*
- Yes
- No
Witnesses*
- Yes
- No
If yes, where
Consent*
By submitting this form, you certify that the information provided is accurate and complete to the best of your knowledge. Your submission constitutes your electronic signature.