Staff Injury Report

Staff Injury Report
Submitted by: Date of Report:  
1st person of authority notified:  
Affected person:    
Affected Person's Information
Last Name:First NameMI: 
State:   Zip: Phone Number: 
Status:# of dependent children:  
Will you return to work today? Will you return to work tomorrow?  
Date of Event:Time of Event: 
Was protective gear provided? Was protective gear worn?  
Location of event (be as specific as possible):  
List all people who witnessed the incident:  
Injury Information
Type of Injury (use Ctrl+ to select multiple types):    Other: 
1.  What side of the body?  1.  Body part/s injured?   
2.  What side of the body?  2.  Body part/s injured?   
3.  What side of the body?  3.  Body part/s injured?   
Nature of Injury:

How did the event occur? (Include cause, antecedants. DESCRIBE IN DETAIL

Website by SchoolMessenger Presence. © 2019 West Corporation. All rights reserved.