InJURY/Illness Report Your Name * First Name Last Name Position Title: Injured Person Details First Name Last Name Email Phone (###) ### #### Nature of Concern * Accident/injury Medical emergency Other Date of Incident MM DD YYYY Time of Incident Hour Minute Second AM PM Location of Incident Bodily Location of Injury Was there any equipment involved in the injury? Yes No Please describe details of the incident, including what happened and how it happened. Were there any witnesses? If so, who were they? Was first aid treatment administered? If yes, please provide first aiders name, treatment provided and who they referred the patient to. Was there anything that could have been done to avoid the situation from occurring in the future? Was the injury/illness reported to the supervisor? Yes No Thank you! Back to Menu
