Incident or Injury Report

Please complete the following report with as much detail as possible.

* : required

Full Name:*Job Title:*

Phone:*Email:*

Date of Injury:*Time of Injury:* :

Date Employer Notified:*Shift Worked on Date of Injury:*

Did Employee Leave Work Early?* Yes No

Circle all body parts injured:*

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List the body parts injured (example: right wrist):*

Describe the incident which resulted in the injury (example: slipped and fell in the parking lot due to snow):*

Employee's Activity When Injured:*

Photos of the Accident Site:

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Job Number/Name:*Job Location (City/State):*

Address of Injury Site:*City:*

State:*Zip:*

Hospital/Clinic Info (if applicable):

Witness Name:Witness Phone:

Job Lead's Name:*

Job Lead's Phone:Job Lead's Email:

Form Completed By:*Form Completed On:*09/24/2025

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