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Employee’s Report of Injury Form
Instructions: Employees shall use this form to report all work related injuries, illnesses, or
“near miss” events (which could have caused an injury or illness) – no matter how minor. This
helps us to identify and correct hazards before they cause serious injuries. This form shall be
completed by employees as soon as possible and given to a supervisor for further action.
I am reporting a work related: Injury Illness Near miss
Your Name:
Job title:
Supervisor:
Have you told your supervisor about this injury/near miss? Yes No
Date of injury/near miss: Time of injury/near miss:
Names of witnesses (if any):
Where, exactly, did it happen?
What were you doing at the time?
Describe step by step what led up to the injury/near miss. (continue on the back if necessary):
What could have been done to prevent this injury/near miss?
What parts of your body were injured? If a near miss, how could you have been hurt?
Did you see a doctor about this injury/illness? Yes No
If yes, whom did you see? Doctor’s phone number:
Date: Time:
Has this part of your body been injured before? Yes No
If yes, when? Supervisor:
Your signature: Date: