Incident Report Form Template: Contractor Incident Report Form

Company name

Subcontractor name if any

First name

Last name

Gender

Date of Birth if available

Address

Phone

Body Part

Lower back
Upper back
Neck

Head / Face
Eye
Leg

Knee
Ankle
Foot / Toes

Hip
Shoulder
Arm / Elbow

Hand / Fingers
Internal Organs
Psychological

Mechanism of Injury

Slips, Trips & Falls
Manual Handling
Hitting Object

Being Hit By Object
Bullying / Harassment
Heat

Electricity
Chemicals
Environment

Hand Tools / Knives
Power Tools

Nature of Injury

Fractures
Sprains & Strains
Cuts & Abrasions

Laceration
Concussion
Mental

Foreign Body
Skin
Infection

Head Injury
Internal system/organs
Bruising

Burns & Scalds
Occupational Disease

Description of the Injury or Illness

Initial Treatment Details

Contractor Status

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Contractor Incident Report Form

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Incident Report Form Templates