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Employee Injury Report Form Template

Streamline Your Reporting Process with This Template

Handling workplace injuries can be chaotic, but a streamlined report will ease your burden. This employee injury report form template helps you efficiently document occurrences while ensuring compliance and safety. By using this template, you can quickly capture vital details, maintain accurate records for workers' compensation, and enhance your business's overall safety protocols, all while saving time and minimizing frustration. Take a look at the live template to start simplifying your reporting today.

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Employee full name
Employee ID or number
Job title
Department or team
Phone number
Supervisor full name
Work email
Date of incident
Time of incident
Incident location type
On company premises (indoors)
On company premises (outdoors)
Offsite client location
Public road or transport
Remote or home workplace
Other or unspecified
Exact location or address
Work activity being performed at the time
Describe what happened
Were unsafe conditions or malfunctioning equipment present?
Yes
No
Equipment, tools, or substances involved
Were any other individuals injured?
Yes
No
Nature of injury (select all that apply)
Body part(s) affected (select all that apply)
Please Specify:
Side of body
Left
Right
Both
Not applicable or unsure
Apparent severity at time of report
First aid only
Medical treatment required
Lost time from work
Fatality
Unknown
Was PPE required for this task?
Yes
No
Not applicable
Was PPE worn?
Yes
No
Not applicable
Medical treatment sought
None
First aid onsite
Clinic or urgent care
Emergency department
Hospital admission
Declined
Unknown
Treating provider or facility name
Current work status
Returned to full duty
Returned with restrictions
Sent home
On medical leave
Hospitalized
Unknown
Were there any witnesses?
Yes
No
Witness name(s) and contact details
Date reported to employer
Corrective actions taken or hazards controlled
Was the incident reported to a supervisor immediately?
Yes
No
OSHA recordable (if known)
Yes
No
Unknown or undetermined
Was a workers compensation claim initiated?
Yes
No
Time lost from work so far
None
Less than 1 day
1-3 days
4-7 days
More than 7 days
Unknown
Employee signature
Employee signature date
Supervisor review comments
Supervisor signature
Supervisor signature date
I certify that the information provided is true and complete to the best of my knowledge.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
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Paper art illustration depicting an employee injury report form template for FormCreatorAI article.

When to use this form

Use this form right after a workplace injury, even if the employee returns to work. It helps you capture facts while they are fresh, support workers' compensation, and meet policy or OSHA timelines. Supervisors, HR, and safety leads use it when someone slips, gets cut by a tool, strains a back while lifting, or is exposed to chemicals. Include incidents on client sites and in vehicles during work. For a broader narrative from others on scene, pair it with the Employee incident report form. If you need to alert your team about hazards and prevention steps, follow up with an Incident/injury safety alert form. Clear reports speed care, reduce repeat events, and protect your company.

Must Ask Employee Injury Report Questions

  1. What was the date, time, and exact location of the incident?

    A precise timeline and place help you verify shift records and camera footage. This data also reveals patterns and hotspots across worksites so you can target fixes.

  2. What task were you doing, and what tools, equipment, or substances were involved?

    Context shows whether training, PPE, or procedures need updates. It also flags equipment to inspect or remove from service.

  3. What injuries did you sustain and which body parts were affected?

    Clear injury details guide medical care and workers' comp coding. They also help gauge severity to plan duty adjustments and return-to-work steps.

  4. Were there witnesses? List names and contact details.

    Witness statements confirm facts and reduce disputes. They fill gaps when the injured person cannot recall every detail.

  5. Was treatment provided, and was the incident reported to a supervisor or authorities? Include where, when, and by whom.

    Treatment info confirms response times and duty of care. If law enforcement was involved, attach or reference a Police incident report form to complete the record.

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