Injury Report Form

Name of Member Involved (required)

Email (required)

Date/Time of Incident (required)

Regular Assigned Work Group or Shift (required)

Type of Incident (required)

Reporting or Emergency Treatment (required)

Location of Incident (required)

Describe the Event [be specific with part(s) of body (i.e. left index finger, right knee, lower back, etc.) and with what type of injury (i.e. bruised, sharp pain, hurts when I walk, throbbing, etc.)] (required)

Witness 1 - Name

Witness 1 - Phone

Witness 2 - Name

Witness 2 - Phone

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