Date of Incident *

Time of Incident

Employee Name

Job Title

Nature of Injury / Illness Select type... Laceration / Cut Fracture / Broken Bone Sprain / Strain Bruise / Contusion Burn (thermal) Burn (chemical) Electric shock Eye injury Head injury / Concussion Back injury Amputation Crush injury Respiratory illness Hearing loss Heat illness Other (describe below)

Body Part Affected Select body part... Head Eye(s) Ear(s) Neck Shoulder Arm / Elbow Wrist Hand / Fingers Back (upper) Back (lower) Chest / Torso Hip Leg / Knee Ankle Foot / Toes Multiple body parts Respiratory system Skin / Dermal

Medical treatment beyond first aid was required

Days Away from Work