Injury Report Form Page 2
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1
2Did the employee stay overnight at the hospital as an in-patient?
[__] Yes [__] No
Case Incident Information:
Case number from the log: #_______________________________________________________
The date of the injury or illness: ____/____/______
The time the employee started work the day of the incident: ____:____ AM / PM
The time of the incident: ____:____ AM / PM [__] Check if no approximate time is available.
Just before the incident occurred, what was the employee doing?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
How did the injury occur?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
What was the specific injury or illness that was a result of the incident?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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