Injury Report | Northwest Traffic

Injury Report Form

Employee Information

Full Name

Street Address

City, ST Zip

Date of Birth

Date Hired

Physician or Health Care Information

Name of Physician or Health Care Professional

Facility (if applicable)

Street Address

City, ST Zip

Accident Detail

Date of Injury or Illness required

Time Employee Began Work

Time Injury/Illness Occurred

Check if time cannot be determined

What was the employee doing just before the incident occurred?

(Describe the activity, as well as the tools, equipment or material the employee was using. Be specific. Examples: "climbing a ladder while carrying roofing materials"; "spraying chlorine from hand sprayer"; "daily computer key-entry.")

(Tell us how the injury occurred. Examples: "When ladder slipped on wet floor, worker fell 20 feet"; "Worker was sprayed with chlorine when gasket broke during replacement"; "Worker developed soreness in wrist over time.")

What happened?

What was the injury or illness?

(Tell us the part of the body that was affected and how it was affected. Examples: "strained back"; "chemical burn, hand"; "carpal tunnel syndrome.")

What object or substance directly harmed the employee

(Examples: "concrete floor"; "chlorine"; "radial arm saw." If this question does not apply to the incident, leave it blank.)

SUBMIT

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