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Injury Report Form

Injury Report Form

Name of person completing this form

Date of Injury

Names of Witness(es):

Body Part(s) Affected:

Is the employee likely to miss additional shifts as a result of the injury?

Name of injured employee:

Approximate Time of Injury:

Nature of Injury (Strain, Cut, Bruise, Ect.):

Was the employee able to finish their shift?

When was their shift ended?

Severity of Injury (If multiple injuries, rate the severity of the most serious):

As the employee was noted transported to a local emergency department or other medical care facility, how were they transported?

Thank you! We’ll be in touch.

Contact Innowave Human Resources

hr@innowavemarketing.com | 352.559.2432

©2024 by Innowave Human Resources.

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