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…”

“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]

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]

Cut / Laceration

Bruise / Contusion

Sprain / Strain

Fracture / Suspected Fracture

Burn (thermal / chemical / electrical)

Puncture / Crush Injury

Repetitive strain / overuse

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]

Area cleaned

Bandage / dressing applied

Ice pack / cold compress

Immobilization / support (splint, sling, brace)

Rest / observation in designated area

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

If Yes:

• Time Called: [HH:MM a.m./p.m.]

• Transported to: [Hospital / Clinic Name]

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

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]

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]

Safety glasses / face shield

Hard hat

Gloves

Safety shoes / boots

Hearing protection

Respirator / mask

High-visibility clothing

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]

Secured or shut down equipment

Marked or restricted access to area

Preserved scene for investigation (if serious incident)

Reminded staff of relevant safety procedures

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.”]

[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]

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]

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]

Photos of incident location or equipment

Medical note or work status form

Internal investigation report

Safety committee review notes