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:
Supervisor at Facility Name
Who did you report it to?
Please select the date and time of the incident:
Please select the time you started your shift:
Names of witnesses (if any)
Was anyone assisting you at the time?
Where, exactly did it happen? (e.g., Room Number)
What were you doing at the time?
Describe step by step what led to the incident.
What part(s) of your body were injured?
Did you get medical treatment?
If yes, whom did you see?
Doctor phone #
Name of treatment facility:
Address of treatment facility:
Has this part of your body been injured before?
If yes, when & what happened?
Please select part of body affected (select all that