Injured Worker Details
Family Name
Notes
First Name
Notes
Company
Notes
Position
Notes
Injury/Illness Details
Time of injury/illness
Notes
Nature of injury/illness
Notes
Bodily location of injury/illness
Notes
Exaction location at time of injury
Notes
Describe how the injury/illness was sustained
Notes
Was any equipment involved in the injury/illness?
Yes
No
Notes
If yes, please provide details
Notes
Employer Confirmation
Signed
Sign
Notes
Witnesses
Were there any witnesses to the injury/illness?
Yes
No
Notes
If yes, please list witness full names and contact numbers
Notes
Follow Up
If yes, please provide details
Notes
Did the injured worker return to work following the injury?
Yes
No
Notes
Was the injury reported to the workers supervisor?
Yes
No
Notes
Was any treatment provided?
Yes
No
Notes
If yes, please provide details
Notes
Details of person making this entry
Family Name
Notes
First Name
Notes
Position
Notes
Signature
Sign
Notes
Date
Notes
If you are not the injured worker, did you witness the injury/illness?
Yes
No
Notes
To be completed by manager/supervisor of injured worker
Has an investigation been conducted into the incident?
Yes
No
Notes
What, if any, controls were implemented to ensure the incident doesn’t happen again?
Notes
Employer confirmation
Employer Signature
Sign
Notes
Date
Notes