Employee Injury Report

Risk Manager Investigator *

First

Last

Name of the injured employee *

First

Last

SS# of injured employee

Employee's home address *

Address Line 1

Address Line 2

City

State

Zip Code

Employee's Phone Number *

Employee's Date of Hire *

Employee's position

Class code

Injury

Date / Time of injury *

Date

Time

Date and Time injury was reported *

Date

Time

Who did you report injury to?

Type of injury

Body part injured (ask for particulars)

Where injury took place?

Were there any witnesses?

Yes
No

Names of Witnesses

If more than 1, separate names by comma

Summary of injury as you know it

Was there any obstruction of any kind?

Yes
No

Report submitted by the supervisor

Type of footwear the employee was wearing

Type of surface slipped on

The name of the clinic the employee went to

phone number of the clinic

Treatment provided by the clinic (if known)

What are the wages of the employee (or per hour)

Who was the injury reported to?

Any additional notes?