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Employee Injury Report Template
Clearly record employee workplace injuries for HR files, safety compliance, and insurance or workers’ compensation documentation.
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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]
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Learn more about
Employee Injury Report Template
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
EMPLOYEE INJURY REPORT TEMPLATE FAQ
What is an employee injury report?
An employee injury report is a written record completed after a worker is injured on the job. It documents when and where the incident happened, how it occurred, what injuries were sustained, what medical treatment was provided, and what follow-up actions the employer took. HR, safety officers, and insurers often rely on this report when reviewing workplace incidents.
When should an employee injury report be completed?
An employee injury report should be completed as soon as reasonably possible after a workplace incident, ideally on the same day. Many employers require a report for any on-the-job injury, even if it seems minor at first, because some conditions worsen over time and may later relate to workers’ compensation, leave, or accommodation requests.
What information should an employee injury report include?
A helpful employee injury report typically includes: basic employee details, date and time of the incident, exact location, job task or activity at the time, a factual description of what happened, body parts injured and type of injury, immediate first aid or medical treatment, witness information, supervisor/manager response, and any initial corrective or safety actions taken.
Can this employee injury report be used for workers’ compensation or insurance claims?
Yes. This Employee Injury Report Template can be used as a supporting document for workers’ compensation or other insurance claims. However, some insurers or government agencies also provide their own required forms. Employers should use this template alongside any official workers’ compensation or OSHA-style forms required in their jurisdiction.
Is an employee injury report the same as an official OSHA or government form?
No. This template is a general internal incident report and is not a substitute for any specific OSHA, government, or insurer forms that may be legally required in your area. Employers should check local laws, regulations, and insurer requirements to ensure all mandatory reporting is completed on the correct forms.
Can AI Lawyer help me draft or adapt an employee injury report?
Yes. AI Lawyer can help you tailor this employee injury report template to your business by suggesting wording, structure, and sections. You still need to provide accurate facts about each incident and follow all applicable legal and safety requirements. For legal advice about workers’ compensation, liability, or regulatory compliance, you should consult a licensed attorney or qualified safety professional.
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