Employee Investigation Report
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Nature of the serious injury (optional — complete only if there has been an injury) Life threatening or resulting in loss of consciousness Punctured lung or other serious respiratory condition Major broken bones in head, spine, pelvis, arms, or legs Injury to internal organ or internal bleeding Major crush injuries Injury likely to result in loss of sight, hearing, or touch Major cut with severe bleeding Injury requiring CPR or other critical intervention Amputation of arm, leg, or large part of hand or foot Diving illness such as decompression sickness or near drowning Major penetrating injuries to eye, head, or body Serious chemical or heat/cold stress exposure Severe (third-degree) burns Other Page 2 of 4 (R16/12) (specify) 52E40 Employer Incident Investigation Report (EIIR) 11..
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