Injury Intake Phone Survey
Please provide detailed information regarding the injury incident for accurate assessment and follow-up.
Full Name of Injured Person
*
First Name
Last Name
Phone Number of Injured Person (if available)
Please enter a valid phone number.
Format: (000) 000-0000.
Date and Time of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Incident
*
Type of Injury
*
Please Select
Sprain/Strain
Fracture
Cut/Laceration
Burn
Bruise/Contusion
Other
Body Part(s) Affected
*
Head
Neck
Back
Arm/Hand
Leg/Foot
Torso/Chest
Other
Please rate the severity of the injury
*
1
2
3
4
5
Briefly describe how the injury occurred
*
Was first aid or medical attention provided?
*
First aid provided on site
Sent to medical facility
No treatment required
Other
Were there any witnesses?
*
Yes
No
If yes, please provide witness name(s) and contact information
What follow-up actions are required?
Contact injured person
Arrange further medical evaluation
Workplace safety review
No further action needed
Other
Submit Survey
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