I njury Report Form

Name of Employee injured:

Location of Injury:

Date: Time:

Description of Injury:



Location where injury occurred:


Was First-aid required: Y / N

Type of first aid administered:

First aid was administered by:

Was further medical attention/ treatment required: Y / N

Name of Medical provider:

Witness to injury:

Work cover claim: Y / N

Notes:







Employee Signature: ______________________________ Dated: _______________________

Manager Signature: _______________________________Dated: _______________________