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Workplace Injury Report Form
Form to document a workplace injury or illness, initiating the workers' compensation claim process and satisfying OSHA reporting requirements.
PDF TemplateUse the instructions below to complete this form
Instructions
Complete within 24 hours of the incident. Record the employee's name, date, time, and location of the injury. Describe the incident in detail: what happened, what the employee was doing, and any equipment involved. List witnesses. Describe the injury and first aid or medical treatment provided. Identify any safety violations or hazards that contributed. Submit to HR, the workers' compensation insurer, and retain for OSHA records.