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Emergency Response Program
Employee Injury Report
Employee Information
Employee Name
First
Last
Phone
Injured Person Information
Injured Person Name
First
Last
Role / Position
Select Role
Employee
Supervisor / PM
Subcontractor
Visitor
Phone
Incident Details
Date of Incident
MM slash DD slash YYYY
Time of Incident
Hours
:
Minutes
AM
PM
AM/PM
Location on Site
Type of Injury
Select injury type
Cut / Laceration
Fall / Slip / Trip
Burn
Strain / Sprain
Eye Injury
Other
Describe What Happened
Immediate Response
First Aid Given ?
Yes
No
Sent to Hospital ?
Yes
No
Supporting Documentation
Photo(s) of Scene/Injury (image upload)
Drop files here or
Select files
Max. file size: 250 MB.
Witness Statements (file upload)
Drop files here or
Select files
Max. file size: 250 MB.
Signature / Acknowledgement
I confirm this information is accurate
Signature
