Incident Report Form Template: Injury Report Form

Injury or Illness Severity

First Aid Injury Only
Medical Treatment Only
Lost Time Injury

Was there any lost work time

Yes
No

Detail Any time lost

Injury or Illness Sustained By

First name

Last name

Role or position

Employment Status

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

Staff Status

Unfit for Work
Fully Fit
Partially Fit Restrictions

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