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  • Employee Report of Injury (NEW)

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    Kerry Collins
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    An employee reported a work-related injury, illness, or near miss using a form that collects details of the incident including their name, job title, supervisor, date and time of occurrence, location, description of the incident, potential preventative measures, injured body parts, medical treatment sought, and signature. The form is submitted to the employer, H3O Incorporated, to document the reported incident.

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    An employee reported a work-related injury, illness, or near miss using a form that collects details of the incident including their name, job title, supervisor, date and time of occurrence, location, description of the incident, potential preventative measures, injured body parts, medical treatment sought, and signature. The form is submitted to the employer, H3O Incorporated, to document the reported incident.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    12 views1 page

    Employee Report of Injury (NEW)

    Uploaded by

    Kerry Collins
    An employee reported a work-related injury, illness, or near miss using a form that collects details of the incident including their name, job title, supervisor, date and time of occurrence, location, description of the incident, potential preventative measures, injured body parts, medical treatment sought, and signature. The form is submitted to the employer, H3O Incorporated, to document the reported incident.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    Employees Report of Injury Form

    I am reporting a work related: Your Name: Job title:

    Injury

    Illness

    Near miss

    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 If yes, whom did you see? Doctors phone number: No

    Date: Time: Has this part of your body been injured before?(optional) Yes If yes, when? Employer: H3O INCORPORATED Your signature (optional): Date:

    No

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