Employee Incident Report

Injury/Illness

Instructions: Employees shall use this form to report work-related injuries, illnesses which could have caused an injury or illness – no matter how minor. Timing: Employee completes the form during their work-shift (or within 24-hours of incident).

I am reporting a work related:

Was anyone assisting you at the time?

Did you get medical treatment?

Has this part of your body been injured before?

anatomy selector with labels