Workplace Injury Incident Report

Record what happened when someone gets hurt on the job, from the date of the event to the names and signatures of everyone present. Safety coordinators and site supervisors keep a signed paper trail for each crew member involved. Use it to close out an investigation and support insurance or regulatory follow-up.

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Workplace Injury Report

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Safety Alert

Date

1) Employee First & Last Name

1) Employee Signature

Sign here

2) Employee First & Last Name

2) Employee Signature

Sign here

3) Employee First & Last Name

3) Employee Signature

Sign here

4) Employee First & Last Name

4) Employee Signature

Sign here

5) Employee First & Last Name

5) Employee Signature

Sign here

6) Employee First & Last Name

6) Employee Signature

Sign here

7) Employee First & Last Name

7) Employee Signature

Sign here

8) Employee First & Last Name

8) Employee Signature

Sign here

9) Employee First & Last Name

9) Employee Signature

Sign here

10) Employee First & Last Name

10) Employee Signature

Sign here

11) Employee First & Last Name

11) Employee Signature

Sign here

12) Employee First & Last Name

12) Employee Signature

Sign here

13) Employee First & Last Name

13) Employee Signature

Sign here

14) Employee First & Last Name

14) Employee Signature

Sign here

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