Injury Report Form

Injury Report Form
1. PURPOSE AND SCOPE
Purpose:

This Incident Report Form is intended to provide a standardized method for documenting workplace incidents, injuries, near-misses, property damage, or unsafe conditions. Accurate and timely incident reporting helps organizations maintain compliance with applicable safety and privacy laws, ensure a prompt response, and implement effective corrective actions.

Scope:

This form is used by all participating IWS business units and workers. It applies to incidents involving employees, contractors, visitors, or members of the public on any company owned or controlled worksite or facility, or during the performance of work duties.
2. PRIVACY AND CONFIDENTIALITY STATEMENT
All personal and medical information recorded on this form is considered confidential and must be protected in accordance with HIPAA (Health Insurance Portability and Accountability Act) and applicable data privacy laws. This information is intended for use by the employer’s designated safety personnel, HR representatives, and authorized medical professionals only. Sharing this information beyond authorized parties is strictly prohibited.
3. COMPANY INFORMATION
Company Name
4. REPORTING PERSON INFORMATION
Reporting Person Name

First NameLast Name
Reporting Person Job Title
Reporting Person Email
example@example.com
Reporting Person Phone Number

Area CodePhone Number
5. WORKERS COMPENSATION
Did Worker Receive First Aid or Medical Attention by a thrid party care provider?
Workers Comp Insurance Provider
Workers Comp Claim Number
Workers Comp Contact Information
Workers Comp Documentation

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6. INCIDENT INFORMATION
Date and Time of Injury
Location of Injury
Location of Injury
Was the incident witnessed
Describe what happened
Witness(s)
Witness Statement(s)

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Weather Conditions
Ground Conditions
Slippery, muddy, dry, ice, etc.
Describe all immediate actions taken post-accident
Order of Events
File Upload

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Photos, Emails, Reports, etc.. Cancelof
Were emergency services contacted?
What emergency services were contacted?
7. INJURED PERSON (IP)

Access to this section only allowed to employer’s designated safety personnel, HR representatives, and authorized medical professionals. Viewing the information in this section by unauthorized parties is strictly prohibited.
IP Name

First NameLast Name
IP Employer/Company
IP Email
example@example.com
IP Phone Number

Area CodePhone Number
IP Relationship to Company
IP Date of Hire

MonthDayYear
Date
IP Date of Birth

MonthDayYear
Date
IP SSN Last 4
IP Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation of IP
Years of Experience
IP Pay Rate
Salary of Hourly
IP Gender
8. INJURY DETAILS

Access to this section only allowed to employer’s designated safety personnel, HR representatives, and authorized medical professionals. Viewing the information in this section by unauthorized parties is strictly prohibited.
Are you an authorized party?
Type a Injury
Number of Days Away
Description of Injury or Illness
Injury and/or Illness details only in this section!
Body Part Injured
Other
Was first aid administered?
Type of first aid administered?
Who administered First Aid?

First NameLast Name
Was the individual transported for medical care?
Facility Name and Address (if medical treatment was received)
Physician Reports/Medical Treatment Reports

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9. INVESTIGATION

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Does this incident require an investigation?
Lead Investigator
Investigation Team
Contributing Factors

Select all that apply
- PEOPLE
- Other
- PROCESS
- Other
- EQUIPMENT
- Other
- MATERIALS
- Other
- ENVIRONMENT
- Other
- MANAGEMENT
- Other
- MEASUREMENT
- Other
- Contributing Factors
- Contributing Factors
- Direct Outcome (What Happened?)
- Contributing Cause(s) (Why did it happen?)
- Root Cause(s)
- Summary of Root Cause(s)
- Corrective Actions(s)
- 10. STATUS
- Injury Report Status
- Date Incident Was Closed
  
  MonthDayYear
  Date
- Name of Person Who Closed the Incident
  
  First NameLast Name
- Should be Empty:

Injury Report Form

1. PURPOSE AND SCOPE

2. PRIVACY AND CONFIDENTIALITY STATEMENT

3. COMPANY INFORMATION

4. REPORTING PERSON INFORMATION

5. WORKERS COMPENSATION

6. INCIDENT INFORMATION

7. INJURED PERSON (IP)

8. INJURY DETAILS

9. INVESTIGATION

Contributing Factors

Contributing Factors

10. STATUS