Employee’s Report of Injury Form

Instructions: Employees shall use this form to report all work related injuries, illnesses, or
“near miss” events (which could have caused an injury or illness) – no matter how minor. This
helps us to identify and correct hazards before they cause serious injuries. This form shall be
completed by employees as soon as possible and given to a supervisor for further action.

I am reporting a work related:  Injury  Illness  Near miss

Your Name: Fred Flinstone, 123 Yabba Dabba Street, Bedrock, CA 92801, 714-808-4500, DOB
09-30-1960. Full Time employee/Employee start date 9/30/1985
Job title: Bronto Crane Operator
Supervisor: Mr. Slate
Have you told your supervisor about this injury/near miss?  Yes  No
Date of injury/near miss: 9/30/1995 Time of injury/near miss: 10:25am

Names of witnesses (if any): Barney Rubble

Where, exactly, did it happen? In the rock quarry station number 3.

What were you doing at the time? Operating the Bronto Crane

Describe step by step what led up to the injury/near miss. (continue on the back if necessary): I
was removing a large rock from the quarry floor with the brotno crane and there was a big gust of
wind. The wind caused the bolder to sway and the bolder slammed into the me and the bronto
crane. The bolder hit my right shoulder and arm.

What could have been done to prevent this injury/near miss? Not sure

What parts of your body were injured? If a near miss, how could you have been hurt? My right
shoulder was bruised, and my right arm was broken.
Did you see a doctor about this injury/illness?  Yes  No
If yes, whom did you see? Dr. Sam Sawbones, Doctor’s phone number: 714-867-5309
Bedrock Hospital, 456 Hospital Dr. Bedrock,
CA 92801
Date: 9/30/1960 Time: noon
Has this part of your body been injured before?  Yes  No
If yes, when? Supervisor:
Your signature: Fred Flinstone Date: 9/30/1960