Employee Injury Report Form

Name of Person Injured
First NameLast Name
Birth Date
MonthDayYear
Phone Number
Area CodePhone Number
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip CodeCountry

Location where injury occured
Body Part Injured
DESCRIBE WHAT HAPPENED: Include conditions present at the time: weather, construction, cleaning, activity going on etc.
DESCRIBE ACTION TAKEN OR ASSISTANCE GIVEN: First Aid, CPR, Police, EMS, Fire and Rescue called?

If Injury, did Injured person refuse treatment?
If injured REFUSES Treatment, injured MUST SIGN here that they REFUSED TREATMENT:
Today's Date
MonthDayYearHourMinutesAM/PM Option
Witness to Incident - Injury - Refusal of treatment
Full Name
First NameLast Name
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip CodeCountry
Witness to Incident - Injury - Refusal of treatment
Clear
Today's Date
MonthDayYearHourMinutesAM/PM Option

"The RAC" Injury Report