Injury Report Form
An Injury report form is a form that is used to provide the details of an injury that has happened at any organization, institution or at any other location. These types of forms can be prepared by police department or by any official staff member of the concerned company/organization. The form provides details about the type and consequences of injury that has taken place.
Sample Injury Report Form
General Information
Name of Organization/Workplace_____________ Location__________
Address___________ Phone Number___________ Email____________
Person Preparing Report__________ Designation_________ Phone_______
Injury Report Information
Date of Injury__/___/___ Time/Hours_____
Effected Person_______
When was the Injury reported to the supervisor: Date__/___/___ Time/Hour________?
Type of Injury____________
Place where it occurred________
Describe the circumstances that caused the injury___________
Describe the activities of the affected person at the time of injury_________________
Any witness___________
Any medical treatment provided to injured person__________
Name the Physician/Hospital___________ Address____________ Phone___________
Cost of treatment_____________
Medical receipts/certificates of physician_________________
Signature ___________ Date of report Submission__________
Report Acceptance Information
Signature of recipient___________ Designation______________
Date___/___/___
Submit______
Category: Report Forms
