Employees can use this form to report all work-related injuries, illnesses, or near-miss events no matter how minor. This template is an example of what an incident form should look like and provides samples of the essential information you should include in any incident-related report. After an injury or illness occurs, this document should be filled out immediately by the injured employee and reviewed by a supervisor as soon as possible.
If you feel any of the symptoms, list the areas of the body where you feel them and indicate which type of symptom. (click "Add Body Part")
Specify body part
Symptom
Scale of pain
Take / upload a photo of the body part
Provide details
Was the employee the one who filled out this form?
Do you want medical treatment right now?
Authorization for Release of Medical Information:
I hereby authorize any and all providers of medical or surgical treatment deemed necessary in regard to my reported occupational injury or illness to release any medical information acquired in the course of my treatment
Employee's Signature
Name and Signature of Authorized Person
As told to me by (Name of Injured Employee)
Reason why injured worker could not complete this form:
Please note that this checklist template is a hypothetical appuses-hero example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.
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