Employee Injury Incident Report template
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Indicate body location and type of injury or illness: Head Hands Knees Eyes Legs Neck Trunk Toes Back Arms Internal Other Describe: Wound Amputation Bruise Strain/Sprain Burn Laceration Hernia Foreign body Concussion Fracture Skin Other Describe: 8.. Regional Safety Office, check all that apply: Investigated Reviewed only No action necessary Action pending Copy to files Initial Date DISTRIBUTION: Original to the Ecology Safety Office (Claims Coordinator) NOTE: Attach additional sheets to this report if more space is needed for your comments..
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