Report Only____ Submission of this form does not reflect admission of fault

First Aid _______

OHP __________
ER _______
PERSONAL INJURY/ILLNESS REPORTS
(Supervisors please complete and return to HR immediately)
NAME OF INJURED DATE OF REPORT

LOCATION IN PLANT WHERE INJURY OCCURRED & Assigned Team JOB TITLE SHIFT

DAY & TIME OF ACCIDENT ___:___AM

__ __:__PM
Sun Mon Tues Wed Thurs Fri Sat
DESCRIPTION OF ACCIDENT (indicate specific actions at time of the injury, what the employee was doing.)

ACCIDENT CAUSE (What actually caused the injury/was proper PPE worn?)

SIGNATURE OF EMPLOYEE: DATE: WITNESSES

1.
SIGNATURE OF SUPERVISOR: DATE:
2.

NATURE OF INJURY (specific part of body injured and extent of injury, Use back as reference)

WAS EMPLOYEE WORKING OVERTIME? YES NO # of consecutive days: ___________

DID THIS INJURY OCCUR DURING PM DAY? YES NO

OCCUPATIONAL ILLNESS (specify toxic substance, noise, radiation, etc.)

MEDICAL TREATMENT PROVIDED (describe care given and by whom)

FOLLOW UP INSTRUCTIONS GIVEN (by OHP, STAT CARE, SRHC-ER)

LOST TIME Yes No

To be completed by HR
Page 1
Report Only____ Submission of this form does not reflect admission of fault
First Aid _______
OHP __________
ER _______
Date investigation returned: ____________________

PERSONAL INJURY/ILLNESS REPORT

To be completed within 3 Working Days of Accident by Supervisor and Safety Manager.

NAME OF EMPLOYEE: DATE OF ACCIDENT:

BRIEF DESCRIPTION OF WHAT HAPPENED:

ACTION TAKEN TO PREVENT A REOCCURRANCE

Investigation Team:

Investigation Date:
SAFETY MANAGER COMMENTS:

WAS IT DONE IF NOT, DATE WHEN IT WILL BE DONE DATE COMPLETED

YES NO

SIGNATURE OF SUPERVISOR DATE:

SIGNATURE OF MANAGER DATE:

SIGNATURE OF SAFETY MANAGER DATE:

Page 2
Report Only____ Submission of this form does not reflect admission of fault
First Aid _______
OHP __________
ER _______

EMPLOYEE’S NAME:

Please indicate area of involvement with an X

check
Identified root cause:
Hazard one
Broken Glass
Flying objects
Lifting / Ergonomics
Moving Parts
Analysis tools used:
Slips, Trips & Falls
Hot surface
Electric Shock
Falling Objects
Other
(Change the above to fit your
work)

Note – You will find you typically have repeat injuries or injuries common to your work. Change the Hazard
topics to fit your main injuries.

Page 3
Report Only____ Submission of this form does not reflect admission of fault
First Aid _______
OHP __________
ER _______

ADDITIONAL COMMENTS:

Page 4