Employee Injury Report Template: OSHA Fields, Care & Signatures

Employee Injury Report Template

[Company / Employer Name]

[Company Address]

[City, State/Province, ZIP/Postal Code]

Phone: [Phone Number]

Email: [Email Address]

1. Employee Information

Employee Full Name: [Name]

Employee ID (if applicable): [ID Number]

Job Title: [Job Title]

Department / Work Area: [Department or Area]

Work Location (if different from above): [Site / Facility / Address]

Supervisor’s Name: [Supervisor Name]

Supervisor’s Phone / Email: [Contact Details]

2. Incident Date, Time, and Location

Incident Date: [MM/DD/YYYY]

Incident Time: [HH:MM a.m./p.m.]

Shift Schedule on Date of Incident: [e.g., 8:00 a.m. – 4:30 p.m.]

Location of Incident (building, room, area, job site, etc.): [Location]

Type of Area: [Indoor / Outdoor / Warehouse / Office / Production Floor / Field Site / Other]

3. Work Activity at Time of Injury

Describe the task or activity the employee was performing at the time of the incident (be specific):

[Example: “Lifting boxes onto a pallet,” “Operating forklift,” “Cleaning spill,” “Walking between workstations,” “Driving company vehicle,” etc.]

Was this the employee’s regular assigned duty? [Yes / No]

If No, explain: [Brief explanation]

4. Description of Incident

Provide a clear, factual description of what happened. Avoid opinions or blame; focus on events.

Incident Description:

[Free-text narrative. Suggested structure:

– What the employee was doing immediately before the incident.

– How the incident occurred (sequence of events).

– What object, equipment, or substance was involved.

– How the employee came into contact with the hazard.]

Example prompts (remove before final use):

• “Employee slipped on…”

• “Employee was struck by…”

• “Employee’s hand was caught between…”

• “Employee overreached while lifting…”

5. Injury Details

Body Part(s) Injured (check or describe):

• Head / Face / Neck

• Shoulder / Arm / Elbow / Wrist / Hand

• Chest / Back / Spine

• Hip / Leg / Knee / Ankle / Foot

• Multiple areas

• Other: [Describe]

Side of Body: [Left / Right / Both / Center]

Type of Injury (check or describe):

• Cut / Laceration

• Bruise / Contusion

• Sprain / Strain

• Fracture / Suspected Fracture

• Burn (thermal / chemical / electrical)

• Puncture / Crush Injury

• Repetitive strain / overuse

• Other: [Describe]

Visible Signs of Injury:

[Example: swelling, bleeding, discoloration, limited movement, deformity]

Employee’s Reported Pain/ Symptoms (use employee’s own words where possible):

[Free-text]

6. Immediate Response and First Aid

Did the employee stop work immediately? [Yes / No]

If No, explain: [Brief explanation]

Person(s) Providing First Aid or Initial Care: [Name(s) and role(s)]

First Aid / Care Provided (check or describe):

• Area cleaned

• Bandage / dressing applied

• Ice pack / cold compress

• Immobilization / support (splint, sling, brace)

• Rest / observation in designated area

• Other: [Describe]

Was 911 / Emergency Medical Services called? [Yes / No]

If Yes:

• Time Called: [HH:MM a.m./p.m.]

• Transported to: [Hospital / Clinic Name]

Did the employee seek or receive outside medical treatment? [Yes / No / Unknown at time of report]

If Yes, where: [Clinic / Hospital / Provider Name]

7. Work Status After Incident

Employee left work on the day of incident: [Yes / No]

If Yes, time left: [HH:MM a.m./p.m.]

Employee returned to work the same day: [Yes / No]

Initial Work Status Recommendation (if known at time of report):

• Full duty, no restrictions

• Modified duty / light duty recommended

• Off work pending medical evaluation

• Unknown – awaiting provider’s note

If modified duty is recommended, briefly describe possible restrictions (if known):

[Example: “No lifting over 10 lbs,” “Seated work only,” “No ladder use,” etc.]

8. Witness Information

Witness 1:

Name: [Name]

Job Title / Role: [Role]

Phone / Email (if needed): [Contact]

Brief Witness Statement (summary of what was seen or heard):

[Free-text summary]

Witness 2 (if applicable):

Name: [Name]

Job Title / Role: [Role]

Phone / Email (if needed): [Contact]

Brief Witness Statement:

[Free-text summary]

[Add additional witness sections as needed.]

9. Equipment, Tools, or Materials Involved

List any machines, tools, vehicles, or materials involved in the incident (include ID numbers if applicable):

• Equipment / Tool / Vehicle: [Description and ID/Serial, if any]

• Condition at time of incident (if known): [Good / Damaged / Under repair / Unknown]

Were guards, protective devices, or safety features in place and functioning? [Yes / No / Not applicable / Unknown]

Personal Protective Equipment (PPE) in use at the time (check all that apply):

• Safety glasses / face shield

• Hard hat

• Gloves

• Safety shoes / boots

• Hearing protection

• Respirator / mask

• High-visibility clothing

• Other: [Describe]

If PPE was required but not used, briefly explain: [Explanation]

10. Supervisor / Manager Review

Supervisor / Manager Name: [Name]

Job Title: [Title]

Date and Time Supervisor Notified: [MM/DD/YYYY – HH:MM a.m./p.m.]

Supervisor’s Summary of Incident (if different or additional to above):

[Free-text narrative]

Immediate Actions Taken by Supervisor / Management:

• Secured or shut down equipment

• Marked or restricted access to area

• Preserved scene for investigation (if serious incident)

• Reminded staff of relevant safety procedures

• Other: [Describe]

11. Initial Corrective or Preventive Actions

List any immediate or planned steps to reduce the risk of a similar injury occurring again (if known at time of report):

• [Action 1, e.g., “Repair or replace damaged equipment.”]

• [Action 2, e.g., “Provide refresher training on lifting techniques.”]

• [Action 3, e.g., “Review and improve housekeeping in affected area.”]

• [Action 4, e.g., “Update written safety procedures or signage.”]

Person Responsible for Follow-Up: [Name and Title]

Target Date for Completion: [MM/DD/YYYY]

12. Reporting and Documentation

Was this incident reported to:

• Internal Safety / HR Department: [Yes / No] – Date: [Date]

• Workers’ Compensation Carrier: [Yes / No] – Date: [Date]

• Government or Regulatory Agency (if required): [Yes / No] – Agency: [Name] – Date: [Date]

Related Claim or Case Numbers (if known):

• Workers’ Compensation Claim No.: [Number]

• Internal Incident / Case No.: [Number]

• Other: [Number/Description]

13. Signatures

Employee Statement:

I, [Employee Full Name], have reviewed this Employee Injury Report. To the best of my knowledge, the information I have provided is accurate and complete as of the date below.

Employee Signature: ___________________________

Date: [MM/DD/YYYY]

Reporting Staff Member (if different from employee):

Name: [Name]

Job Title: [Title]

Signature: ___________________________

Date: [MM/DD/YYYY]

Supervisor / Manager Acknowledgment:

I have reviewed this report and will ensure that appropriate follow-up actions are considered and, where approved, implemented.

Supervisor / Manager Signature: ___________________________

Printed Name: [Name]

Date: [MM/DD/YYYY]

14. Additional Notes or Attachments

Additional Notes (optional):

[Free-text area for any other relevant information not covered above.]

Attachments (if any):

• Photos of incident location or equipment

• Medical note or work status form

• Internal investigation report

• Safety committee review notes

• Other: [Describe]