Facial Injury Incident Report Form
Use this form to document a facial injury incident, including what happened, who was involved, the injury details, immediate response, and any medical follow-up.
Reporter and Incident Identification
Reporter Full Name
*
First Name
Middle Name
Last Name
Role / Relationship to Incident
*
Please Select
Employee
Supervisor
Manager
Witness
Family Member
Healthcare Provider
Other
Reporter Email Address
example@example.com
Reporter Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Incident Record / Reference Number
Injured Person Full Name
*
First Name
Middle Name
Last Name
Relationship to Reporter
Please Select
Self
Coworker
Direct Report
Supervisor
Family Member
Other
Incident Details
Date of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Incident
*
Hour Minutes
AM
PM
AM/PM Option
Exact Location of Incident
*
Description of What Happened
*
Injury Assessment
Facial area(s) affected
*
Forehead
Eye
Nose
Cheek
Lips
Jaw
Chin
Mouth
Other
Type of injury
*
Cut
Bruise
Swelling
Fracture
Burn
Abrasion
Other
Severity level
*
Mild
Moderate
Severe
Symptoms observed
Bleeding
Swelling
Pain
Blurred vision
Dizziness
Loss of consciousness
Other
Additional symptom details
Witnesses, Immediate Response, and Medical Follow-Up
Witnesses
First Aid or Immediate Actions Taken
Was Emergency Services or Medical Care Sought?
*
No
Yes, emergency services
Yes, clinic/urgent care
Yes, hospital
Yes, other care
Treatment Provider / Clinic / Hospital Name
Date and Time of Medical Evaluation
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Additional Notes or Contributing Factors
Submit Incident Report
Should be Empty: